ORIGINAL RESEARCH PAPER
Year : 2012 | Volume
: 25 | Issue : 1 | Page : 48--54
Doctor - patient Communication Issues for International Medical Graduates: Research Findings From Australia
P McGrath1, D Henderson1, J Tamargo2, HA Holewa3,
1 Population and Social Health Research Program, Griffith Health Institute, Logan Campus, Griffith University, Queensland, Australia
2 Department of Medicine, Redland Hospital, Queensland, Australia
3 Institute of Health and Social Science, Faculty of Science, Education and Health, Central Queensland University, Brisbane, Australia
Associate Professor, Senior Research Fellow, Population and Social Health Research Program, Griffith Health Institute, PO Box-1307, Kenmore, 4069 Queensland
Introduction: Understanding the impact of culture on medical communication is particularly important for international medical graduates (IMGs) who enter health systems from different cultures of origin. This article presents data on IMGs«SQ» perception of the impact of cultural factors on IMG doctor−patient communication during their integration into the Australian health system. Methods: The methodology used was a descriptive qualitative methodology, using iterative, open-ended, in-depth interviews with a sample of 30 IMGs employed at a hospital in Brisbane, Queensland, Australia. Results: According to subjects«SQ» comments, understanding patient-centered communication is a major challenge faced by IMGs during integration in the Australian health system. They perceive that this difficulty is associated with the major shift from the culture of their country of origin (described as paternalistic doctor-dominated communication system; standard practice to talk to the family and not the patient) to the very different health care culture of Australia (perceived to be more educated and informed consumers that demand high levels of information and discussion). The findings detail IMGs«SQ» experience with learning about patient-centered communication at the point of arrival, during integration and practice. Subjects«SQ» perceived the need to provide education on patient-centered communication for IMGs integrating into the Australian health system. Conclusion: There is a significant need for IMGs to be educated in cultural issues including doctor−patient communication practices in Australia.
|How to cite this article:|
McGrath P, Henderson D, Tamargo J, Holewa H A. Doctor - patient Communication Issues for International Medical Graduates: Research Findings From Australia.Educ Health 2012;25:48-54
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McGrath P, Henderson D, Tamargo J, Holewa H A. Doctor - patient Communication Issues for International Medical Graduates: Research Findings From Australia. Educ Health [serial online] 2012 [cited 2023 Feb 2 ];25:48-54
Available from: https://educationforhealth.net//text.asp?2012/25/1/48/99206
International medical graduates (IMGs) presently represent 25% of the Australian medical workforce.  In Australia, an IMG is defined as a doctor who has obtained their primary medical qualification in a country other than Australia or New Zealand.  There is a complex set of pathways and requirements for IMGs seeking to practice in Australia. The only commonality is that all must have passed an English language proficiency test, unless they have obtained secondary education in an approved English-speaking country. The complex system of pathways reflects the fact that IMGs come from a multiplicity of cultural and medical education backgrounds, varying with their country of origin. Thus, several routes for certification and registration are required to address the varied levels of qualification and diversity of experience.  In relation to this diversity, it is issues associated with the varied cultural backgrounds of IMGs that are the focus of this paper.
Internationally, the impact of culture on medical communication is particularly important for IMGs who enter health systems different from their cultures of origin.  Indeed, lack of cultural competence is noted as a key issue of concern with the quality of care provided by IMGs.  However, to date, research in this area is in its infancy, and, in particular, there has been scant research on communication and cross-cultural communication for IMGs in Australia.  However, this is an important area of research with international consequences, for, as Duncan and Gilbey  explain, understanding the impact of culture on communication is important in health care as good patient−doctor communication promotes a better exchange of information in the consultation and helps build trust and enhances patient autonomy. This is a topic where there needs to be a sharing of experience from different countries as we are all learning from each other. To make a contribution to the literature on this topic, this article presents findings on the impact of cultural factors on IMG doctor−patient communication as perceived by the IMGs. The insights are a subset of findings from a qualitative study based at Redland Hospital, Queensland, exploring the experience of integration of IMGs into the Australian health care system from the IMGs' perspective.
The Redland Hospital is a 140-bed general public hospital that provides emergency, medicine, surgery, obstetrics and gynecology, pediatrics and mental health services. The hospital is staffed by senior full-time medical staff and "junior" or trainee staff. There is a standard complement of allied health staff, including physiotherapists, occupational therapists, speech pathologists and social workers, deployed in the inpatient wards and emergency department. There are well-developed systems of multidisciplinary care involving medicine, nursing and allied health, which include discharge planning, aged care assessment and general social and psychological support.
The study was initiated by the then Director of Acute Medicine, Dr. David Henderson, at the Redland Hospital and funded by the Bayside District Health Service, Brisbane, Queensland. The study is one aspect of the leadership provided by Dr. Henderson and his team at Redland Hospital with regard to the integration of IMGs into Australia achieved through the development of IMG-specific programs  and other research activities. ,,
The participants were enrolled through the Project Officer for the study who was under contract with the University and thus independent of the hospital. The Project Officer was given a list of doctors who had been employed at the hospital along with their telephone numbers. This information was obtained from a hospital representative who had notified potential participants about the details of the study by e-mail and allowed any IMGs to opt out of further follow-up if they elected. The participants were consecutively enrolled from this list, through an initial telephone call or e-mail contact, followed by the Project Officer providing written project descriptions of the project and an invitation for voluntary participation in the research. At this stage, signed consent forms were collected from the participants and enrolment occurred. There was no screening of the participants. All IMGs were presently working at the hospital, with the exception of three who had worked there within the past four years. Before interviewing, the participants were again informed of their ethical rights (i.e., informed consent, confidentiality, right to withdraw). The University Ethics Committee and the Queensland Health Department Human Research Ethics Committee approved the study.
A stratified purposeful  sample of 30 IMGs, which represented the diversity and proportions of country of origins of IMGs employed at the hospital, participated in the research. The primary medical degree held by the IMGs was from a range of countries: India (n = 11); Sri Lanka (n = 4); Iran (n = 3); South Africa (n = 2); Sudan (n = 2); Pakistan (n = 1); Caribbean (n = 1); Russia (n = 1); Philippines (n = 1); Indonesia (n = 1); Egypt (n = 1); Serbia (n = 1); and Afghanistan (n = 1). The majority of IMGs (n = 20; 66.6%) came directly from their country of origin to practice in Australia. The IMGs who spent time in other countries prior to coming to Australia predominately went to the United Kingdom (n = 5; 16.6%), with others spending time in the health system in Iran (n = 1), New Zealand (n = 2), Oman and Fiji (n = 1) and Pakistan (n = 1). The length of time that the IMGs had been in Australia at the time of the study ranged from 2 to 17 years (since 2005, n = 15; 2000, n = 5; 1995, n = 4; 1990, n = 2; not available, n = 4). There were nineteen male and eleven female participants.
Because the participants were enrolled from a small, identifiable group at the hospital, the informed consent procedures gave a strict commitment to confidentiality and a guarantee that no further identifying information would be presented or published with the findings. Hence, further demographic description will not be provided to protect the identity of the participants.
A descriptive, open-ended, exploratory qualitative design was utilized for the study. Qualitative research was used to evaluate programs in health care to provide insights on quality and effectiveness and to assist in program improvement. , Such a qualitative approach was particularly appropriate where little was known about an issue , and, thus, was well suited to a study that explored the experience of integration for IMGs in Australia where there is scant research literature available.
The exploration of the IMGs' experience with integrating into the Australian health system was conducted through an iterative, qualitative research methodology using open-ended interviews conducted at the time and location of each participant's choice. Doctors were given the option for the interview to be conducted by telephone rather than in person; all opted for telephone interviews. The interviews were conducted by a researcher with a background in cross-cultural research employed by the University and thus independent of the hospital.
The IMGs were encouraged to talk about their experience as a doctor prior to, during and following their integration into the Australian health system. The line of questioning included the techniques of probing, paraphrasing and clarification to explore each participant's experience.  The initial data on the topic of cultural issues in communication were provided by participants in response to the question, "What issues did you find most difficult to adjust to when integrating into the Australian health system?" As all the participants in the initial interviews discussed cultural issues as part of the response to the question, the decision was made, based on the iterative principle of qualitative interviewing, to ensure this topic was included in all interviews with subsequent participants. The interviews lasted for approximately 1 h and were audio-recorded. The interviews were transcribed verbatim by a research assistant independent of the hospital.
The language texts were then entered into the QSR NUD*IST (N5 1995) computer program and analyzed thematically. All participants' comments were coded into "free nodes," which are category files that have not been pre-organized but are "freely" created from the data. There was no mediation of the data as all the participant's statements were coded without a pre-formed schema or hierarchy. The code names were developed directly from the content of the participant statements reflective of the expressed meaning of the statement. The list of codes was then transported to a Word Computer Program (Word 97) and organized under thematic headings. The coding was established by an experienced qualitative researcher and completed by the Project Officer who has extensive experience with coding qualitative data. There was complete agreement on the coding and emergent themes between the coders and the researchers. Of the 201 free nodes created from the transcriptions, the ones directly related to the topic of the IMGs' experience with doctor−patient communication issues in Australian medical culture are presented in this article.
Interviewees' comments indicate that understanding patient-centered communication is a major challenge faced by IMGs during integration in the Australian health system (Theme: Understanding the culture of patient-centered communication is a major integration challenge). The difficulty is associated with the major shift from the culture of country of origin (described as paternalistic doctor-dominated communication system; standard practice to talk to the family not the patient) (Themes: Cultural background - in many of the countries of origin, it is usual for patients to do what the doctor decides without question; Cultural background − in country of origin it is common for the physician to talk to the family not the patient) to the very different health care culture of Australia (where patients are perceived to be more educated and informed consumers that demand high levels of information and discussion) (Theme: Australians are seen by IMGs to be more educated and wanting information). The finding details IMGs' experience with learning about patient-centered communication at the point of arrival, during integration and at their present stage of practice (Themes: Understanding of Australian doctor−patient communication practices; Integration in the Australian medical culture). The findings conclude with a discussion of subjects' perception of the need to provide education on patient-centered communication for IMGs integrating into the Australian health system (Theme: Need for IMG education on patient-centered communication).
Understanding the culture of patient-centered communication is a major integration challenge
During the discussion of the experience of integration into the Australian health system, the IMGs posited dealing with cultural issues associated with patient-centered communication as professionally challenging.
[Sri Lanka] It is a huge learning area.
Cultural background - in many of the countries of origin, it is usual to do what the doctor decides without question
IMGs are unprepared for patient-centered communication because of their medical practice experiences prior to coming to Australia. There was extensive discussion of the fact that many of the IMGs came from countries of origin where patients simply, and without discussion, do what the doctor decides. This was a common cultural experience for IMGs from a wide range of countries.
[South Africa] It was a difference…………… you speak to the patient: "this is what I think you should do for these reasons" and the patient said: "you're the doctor."
[India] Whereas in India, it is not our culture. Usually, they do not doubt the doctors, they just leave their decisions on the doctors and they are just happy with whatever the doctor decides for them.
As the patient is not engaged in an information discussion, the medical consultation is much faster than in the Australian health system.
[India] Whereas in India I would probably tell the patient what I'm going to do, but it would be much shorter because over there they do not want that much information.
It was noted that such medical communication is based in a culture of faith and trust in the competency of the doctor.
[Pakistan] Over there, they believe in you. You are the doctor and they think whatever you do is best for them. They have complete faith in you, and they believe in you.
However, even in these countries, the process of doctor−patient communication can differ in different parts of the country.
[Russia] Some parts (of Russia) are the same (in relation to these issues) while some parts are different.
Differences also occur over time and depend on the level of practice.
Cultural background − in country of origin it is common for the physician to talk to the family, not the patient
Many participants indicated that in their country of origin it was common not to talk directly to the patient. In their country of origin, many IMGs talk to the family representatives rather than to the patient.
But [in Iran] most of the people used to present with a lot of families and relatives. They share the secrets. But, in our life here you deal with the patient as a person and then you tell his wife, his mum or anybody. He is the person you need to talk to.
In some countries, the focus on the family rather than the patient and the lack of information-giving during the terminal trajectory means that the patient is not told that they are dying.
[Afghanistan] It is quite different from what happens in Afghanistan. For example, in Afghanistan if someone has cancer usually the family does not tell them until… But then here you actually tell the patient.
Australians are seen by IMGs to be more educated and wanting information
The difficulty is associated with the major shift from the culture of country of origin to the very different health care culture of Australia. The IMGs spoke at length about the different attitude that Australians have to medical decision-making. The participants indicated that they were aware that in Australia it is standard doctor−patient communication practice to talk to the patient.
[Sri Lanka] … here it is the patient. If he or she wants to know you have to tell them, and relatives come second. As long as somebody has the mental capacity [you inform them]. So in that way a little bit different.
The comments refer to Australians as more educated and informed.
[India] Because the population is more educated here [in Australia], they want good answers from the doctors and good explanations. And they want to know more and they go on the Internet and search a lot of things. So the patient is already well informed and so you have to be very careful about what you tell them and give them right information.
Australian patients are described as more demanding and requiring more information.
[Sudan] Australian patients want to know everything about themselves, the diseases, how, you know. You need to teach the patient, or tell them about the disease, the prognosis, the treatment, the management, the ongoing management. So you need to be more careful with the patients.
Thus, the process of information-giving and patient-centered communication is seen as time-consuming.
Understanding of Australian doctor−patient communication practices
Many of the IMGs indicated that they were not aware of the cultural difference with regards to doctor−patient communication when they arrived in Australia. For these doctors, the cultural learning had to happen during their initial employment.
[Iran] So we might make these mistakes here because we do not know the system.
Some of the IMGs had prior experience in countries such as the UK with similar patient-centered communication and so arrived in Australia with an understanding of what was required in patient care. These IMGs valued such prior experiences and considered that the knowledge they learned from their prior positions assisted their integration into the Australian health system. Others based their working knowledge on experiences in locations in their country of origin that were similar.
[India] Whereas in Delhi you could not [tell patients what to do], so that actually helped me a great deal when I came to Australia because I realized I have to conduct myself like I am working in the hospital in Delhi.
Some IMGs indicated that it only took a number of months on arrival in Australia to gain a working knowledge of patient-centered communication.
[Sri Lanka] The main thing was I had a little bit of problem, communication problems. After a few months I was able to pick up all those things and I did not have any problem after that.
However, others indicated that understanding such cultural issues is a slow process that can take many years.
[India] It is difficult to understand, to get it within 6 months or so.
It takes years for you to get these things, and get into the culture. I do not think that that could happen within 6 months or 1 year. It is a slow process, you know.
Integration in the Australian medical culture
Many of the IMGs made clear statements to indicate that they presently understood, valued and felt comfortable with the practice of patient-centered communication.
[India] I like that aspect (patient-centered communication), I like that aspect a lot.
[Afghanistan] I quite like it because they have to know, it is their health, they have to know what is happening so that they make a decision.
Indeed, there were comments that the open exchange of information was seen as not only positive for the patient but also as contributing to better clinical practice.
[India] You have to have a much clearer idea of the background before you make a diagnosis… so that really helps, the fact that people are very open, that helps a great deal.
However, there were also statements indicating that for some IMGs this was a difficult task and something they continue to find challenging.
[South Africa] Whereas over here I do, and I still battle with that… It was a bit of an issue in that yes, I came from a country where the doctor was God.
For one doctor, the patient-centered communication was seen as in direct contrast to the sense of respect given to doctors in the country of origin.
[South Africa] The doctor is not even respected [in Australia]. And that I think is quite hard to contend with because you know how much study you have done. And yet that is not being acknowledged by people who have not got any of that knowledge. So this is a big, big step.
Need for IMG education on patient-centered communication
Understanding the Australian process of patient-centered communication is important to the IMGs in this study. Many had assimilated the ideas by osmosis through immersion in the culture or through discussions with others. However, it is noted that there is a profound need for education on this topic for IMGs entering the country. Some indicated that education on the topic should happen before taking up practice. Others argued that it should be an ongoing educational process during integration.
[Caribbean] People need to be de-sensitized to what they know. Because if you do not do that they will still continue to do the way things they used, how they used to do.
The findings highlight the fact that understanding and engaging in the Australian medical culture of consumer-oriented doctor−patient communication is perceived by the IMGs as a significant professional issue that needs to be addressed during integration into the Australian health system. At the core of the concern is a difference in approach between a doctor-imposed, as opposed to a consumer-oriented, patient-informed communication process.
The IMGs in the study reflected the cultural diversity and multiplicity of perspectives noted in other countries.  For many of the IMGs, the process of patient-centered communication, which takes time and detailed provision of information directly to the patient, was not part of the medical culture of their country of origin. This observation is qualified by regional, hierarchical and time differences. Many of the IMGs came from countries where the doctors' status was high and neither patients nor their family questioned the doctors' authority. This finding resonates with the literature that indicates that in many of the countries of origin for IMGs, doctors are highly regarded and operate from positions of considerable power both in medical practice and in the community. , Authors such as Singareddy and associates  argue that for IMGs, the experience of arriving from a country of origin with a totally different environment can translate into a form of culture shock. As Dorgan and associates  report from a US study, many IMGs are raised and educated in cultures where doctors are attributed a God-like status, with the expectation normalized that they will be directive during medical interviews and have the power to decide the fates of patients without being questioned or challenged. Patient compliance, trust and cooperation without question is the norm and thus IMGs from such countries would be unfamiliar with the notion of patient-centered communication, where the patient has the right to question.  Canadian research  highlights the need for IMG orientation programs to include the opportunities to reflect on cultural biases and for learning about cultural background and beliefs of a new patient population.
The reasons posited by the IMGs for the doctor-imposed decision-making was the lack of education of the general population in the country of origin, the absolute trust given to doctors and the speed of consultations. In many countries of origin, the doctor consults the family rather than the patient and there is a lack of candour in information-giving. During the dying trajectory, this can result in a patient not being informed that they are dying.
At the time of the interview, the IMGs were aware of the different culture of doctor−patient communication in Australia. The perception was that Australians are more educated, more informed, more demanding of information and more time consuming to deal with in medical practice. However, on arrival, many IMGs do not know about these differences. This finding resonates with the literature that posits as a major challenge for IMGs the need to adjust to the "medical subculture" or the way medicine is practiced in Australia, including doctor−patient communication.  However, some may be aware of patient-centered communication from experience elsewhere or from parts of their country of origin that embrace similar processes of medical communication. The IMGs indicated that it can take from months to years to understand and work effectively in such a different medical culture. It is of concern that a study of IMG registrars and their supervisors in an Australian General Practice Training Program noted such cultural problems and recorded that these issues were still salient despite all the registrars interviewed having lived in Australia for at least 11 years. 
The Australian practice of medical communication was valued by many IMGs and seen as beneficial not only for the patient but also for clinical practice. However, others were still struggling with the concepts and practice. For these IMGs, the practice of providing detailed information to the patients to ensure informed choice was perceived as disrespectful of doctors' expertise, irksome and time-consuming.
The findings from the study are from interviews with a diversity of IMGs from one hospital. In view of the strong resonance of the findings with the international literature, especially research completed in the USA, Canada and NZ, there are strong indications that the phenomenon reported is representative of the IMG experiences elsewhere. Although there is scant Australian research on the topic and the work that is available focuses on the rural community rather than the hospital setting, ,, the available studies confirm the direction. However, the study would have to be extended, with further data collection both at a state and at a national level, for further understanding of the depth and extent of the problems for IMGs in hospitals throughout Australia.
Also, the focus of the findings and discussion is on the perspective of the IMGs. Further research is required on issues associated with the Australian health care culture and the perspectives of the health professionals that work with the IMGs.
To the extent that the views of the IMGs in this one hospital reflect the views of IMGs working in other Australian hospitals, a recommendation from the findings is the need for IMG education on doctor−patient communication both before starting practice and during their ongoing integration into the Australian health care system. This article contributes to the increasing concern in the literature that indicates that IMGs are not being adequately provided with training in doctor−patient communication skills during their process of integration. ,,,,, Anecdotal Australian evidence  indicates that IMGs desperate for any training now select hospitals with better-resourced training programs. However, as most of the recent research on this topic has been completed in the USA, ,, Canada  and New Zealand, , the findings from the present study provide an up-to-date Australian empirical perspective on IMG need for education in communication issues.
The findings from the present study indicate that communication skills need to be more than English proficiency and the use of idioms, nuances and vernacular terms, but must include the deeper issues outlined in Hawken's  New Zealand study of communicating empathy, reflective listening and rapport-building. A similar qualitative American research emphasizes that IMG training needs to address communication barriers associated with cross-cultural differences in norms, values and beliefs.  IMGs integrating into the Australian health care system need training to develop the skills required for equitable, patient-centered medical communication.
This paper is one response to Rao and associates'  call for a greater understanding of IMGs' training needs and a deeper appreciation of the impact of their cultural differences in order to engender measures to fully integrate them into the health care system. The findings from the present study highlight the need for medical education and training in Australia to respond to and further explore the impact of cultural difference in communication for IMGs.
The authors would like to thank Stasia Kail-Buckley, Mary Anne Patton and Elaine Phillips for their contribution to the research and Redland Hospital, Bayside District Health Service, Brisbane, Queensland, for funding for the project. The authors wish to acknowledge that the data were collected at CQUniversity and analyzed and written up at Griffith University.
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