Abstract
Objective To explore experiences of international medical graduate (IMG) FPs in providing cross-cultural patient care and to identify rewards and challenges they experienced when caring for patients of cultural backgrounds different from their own.
Design Descriptive qualitative study.
Setting Family medicine primary care practices in Alberta.
Participants Eighteen IMG FPs practising in the metropolitan areas of Edmonton or Calgary in Alberta as of May 2013.
Methods Individual face-to-face or telephone interviews were conducted using a semistructured interview guide. Seventeen interviews occurred between July and August 2013 and 1 took place in August 2014. All interviews were audiorecorded and transcribed verbatim. Transcribed data were subject to thematic analysis.
Main findings International medical graduates identified several rewarding aspects of caring for patients with cultural backgrounds different from their own, including learning about different cultures, perceiving that appointments are more succinct, and advocating for patients whom they perceive to be at a disadvantage. Family physicians also identified several challenges associated with caring for patients of different cultural backgrounds, including encountering language barriers, perceiving that visits take longer, and experiencing patients’ lack of acceptance of FPs with cultural backgrounds different from their own.
Conclusion Cultural differences between FPs and patients can enhance or undermine doctor-patient relationships. The results of this study speak to the need for cultural competency training for FPs practising in culturally diverse settings.
In Canada, international medical graduates (IMGs) are physicians who have graduated from medical schools outside Canada or the United States.1,2 International medical graduates represent approximately 25% of the physician workforce in Canada3 and are instrumental in providing health care to Canada’s multicultural population, which is composed of individuals from approximately 200 countries of origin.4 International medical graduates also come from diverse backgrounds, ethnicities, and races and speak various languages5; as such, cross-cultural care is an integral part of primary care practice in Canada.
Providing cross-cultural care embodies many CanMEDS–Family Medicine roles, including but not limited to physicians taking on the roles of family medicine expert, health advocate, and communicator.6 As communicators, FPs are expected to facilitate culturally appropriate conversations with patients and their families, which includes conducting culturally safe interviews that are respectful and nonjudgmental.6 As such, physicians are expected to develop trusting relationships with patients that are empathic, respectful, and compassionate.6
Physicians’ abilities to develop trust with their patients are influenced by culture.7,8 When transitioning into practice, IMGs not only have to adapt to unfamiliar cultural norms but may also encounter language barriers and face discrimination.7,9-11 These challenges can affect their abilities to establish safe and trusting relationships with patients from diverse backgrounds. Yet despite the challenges associated with cross-cultural care, IMGs in Canada tend to believe they are well prepared to provide care to immigrant populations.7 For IMGs who have left their countries of origin to establish careers and lives in Canada, it is common to have to negotiate and overcome many challenges, including differences in the health care system and in health care subcultures.12 For this reason, IMGs who have emigrated from other countries have been known to demonstrate high levels of empathy, particularly toward immigrant patient populations, as they understand some of the challenges they may face, clinically or otherwise.7
Despite the emphasis on providing culturally appropriate care in Canada, the experiences of IMG FPs related to providing cross-cultural care in Canada have not yet been examined and reported in the literature.7 Therefore, the purpose of this study was to explore IMG FPs’ perceptions of the rewards and challenges of providing cross-cultural care in the Canadian context.
METHODS
Study design and participants
This interpretive qualitative study drew on constructivist grounded theory methodology. As our goal was not to generate a substantive theory but rather to explore participants’ perceptions, we did not approach the research with an overarching theoretical framework; rather, we were sensitized to concepts drawn from the literature on IMGs as part of our analysis and interpretation of study findings.
This qualitative study was part of a larger project that included a quantitative phase with the same overall goal of understanding cross-cultural patient relationships and the rewards and challenges IMG FPs face when providing cross-cultural care. This qualitative study followed the quantitative phase and employed semistructured interviews to explore in-depth experiences of IMG FPs in providing care to culturally diverse patient populations.
In this study, IMGs were defined as FPs or general practitioners practising in Canada who had graduated from medical schools in countries other than Canada or the United States. This group includes individuals who were born and raised outside Canada (I-IMGs) as well as Canadians who studied abroad for their undergraduate medical education (C-IMGs) who then did residency training in Canada. International medical graduate FPs registered with the College of Physicians and Surgeons of Alberta and practising in Edmonton or Calgary (N=765) as of May 2013 were included in the study sample.
Data collection
As part of the quantitative research, a questionnaire package that included an information letter, a questionnaire, and a reply card that asked individuals to indicate whether they were interested in participating in a qualitative interview was sent to potential participants in May 2013. Recipients were asked to reply within 2 weeks, although responses were accepted beyond that time frame. International medical graduate FPs who responded to the questionnaire and volunteered to participate in the qualitative study (n=18) were contacted to set up interviews.
One author (J.T.), a trained qualitative interviewer, conducted 17 interviews in person or via telephone between July and August 2013 and 1 interview in August 2014. All participants provided written or verbal audio-recorded consent before the interview was conducted. Ethics approval was obtained from the Health Research Ethics Board at the University of Alberta and the Conjoint Health Research Ethics Board at the University of Calgary. All interviews were audiorecorded and transcribed by a transcription service.
Interview questions addressed rewards and challenges of caring for patients of different cultural backgrounds than their own; the influence of cross-cultural issues on the patient-doctor relationship; and challenges in everyday practice related to cross-cultural care. At the start of each interview, participants were asked to describe with which culture they self-identified. We intentionally did not define culture so as not to constrain participants’ conceptualization of their cultural identity and to allow participants to elicit their avowed identities, as this more closely aligned with the aim of our research study. Within the context of this study, the term cross-cultural patient care refers to participants’ reported instances of providing care to patients whom they perceived to be from cultural backgrounds different from their own.
Data analysis
Consistent with a generic qualitative approach and constructivist grounded theory, an inductive thematic analysis using constant comparative analysis was conducted.13 Thematic analysis began with an independent review of the transcripts to gather a holistic sense of the data.14 The study investigators independently read through transcripts line by line to inductively develop initial codes and memos related to key words, sentences, and paragraphs that spoke to meaning within the data. The investigators met regularly to go through each transcript to compare identified codes and memos. The team identified themes that helped explain how codes and memos fit together. Analysis was iterative, with themes re-examined and modified at each group meeting to include new transcripts and emerging data. Data collection and analysis continued until thematic saturation was reached.15 Themes were deemed to be saturated when further data collection was not deemed to contribute to advancing our understanding of the data, as no new themes had emerged, and our understanding of existing themes had not been enhanced with the additional data collected in the past several interviews. Qualitative analysis software (NVivo) was used to record consensus data and maintain an audit trail that all researchers could access.
Reflexivity
A graduate research assistant (J.T.) affiliated with the Department of Family Medicine at the University of Alberta conducted the interviews. The research assistant had no prior relationships with research participants. The research team consisted of 3 nonclinician researchers (J.T., O.S., and K.D.) and 2 physician researchers (S.K. and M.B.), of whom 1 is an I-IMG (M.B.). The variety of IMG and Canadian physicians as well as nonphysician researchers provided an array of perspectives with which to approach the research and the analysis and interpretation of the data.
FINDINGS
Eighteen IMG FPs (11 females, 7 males) practising in Edmonton or Calgary in Alberta participated in this study. Physicians self-identified with a range of cultures, including South Asian, Canadian, Pakistani, East Indian, Iranian, Western European, Scottish, Polish, Filipino, and Russian. One participant self-identified as Caucasian. Two participants were C-IMGs. Two themes emerged from interview participants’ comments: there were both rewards and challenges related to caring for patients from cultural backgrounds different from their own.
Rewards of caring for patients from different cultural backgrounds
The rewarding aspects of caring for patients from cultural backgrounds different from their own, described by participants, could be categorized according to 3 subthemes: learning about different cultures, having appointments take less time than appointments with patients from the same cultural background, and advocating for patients, particularly for those at a perceived disadvantage.
Opportunities to learn about different cultures. Study participants expressed gratification at having opportunities to interact with patients from different countries of origin and different cultural backgrounds. These interactions often resulted in conversations about world news and current events in patients’ home countries. Participants enjoyed learning about others’ experiences and conversing about diverse topics with patients from different cultural backgrounds.
I enjoy meeting people from different parts of the world.… After the official office visit is over, we might just talk about the highlights of their country, what’s happening politically.… [S]o it’s a nice mix to have different people in your practice.… It just makes for an interesting day. (Interview 6; I-IMG, female)
[I]t just makes the work more diversified; I think for the most part for me, it’s a little bit more interesting and I try to have fun with it, learn from it, and enjoy it. (Interview 11; I-IMG, male)
Shorter appointments. Several participants said visits with patients from different backgrounds were succinct and to the point. These physicians believed that these patients were respectful of the physician’s time and used the time available for the visit to address their immediate health concerns adequately.
[I]f they are not from the same ethnic background … they come to the point [regarding] what the complaints are, and [I] do take less time to see those patients. (Interview 8; I-IMG, male)
Other participants noted that patients from different backgrounds who spoke English and had higher levels of education tended to have shorter visits. When patients had higher health literacy levels, physicians did not need to spend as much time on patient education and it took less effort to develop a shared understanding of patients’ health issues. One participant noted that such patients “understand more quickly. So, the main thing is you don’t have to spend as much time with them.” (Interview 17; I-IMG, female)
Advocacy. Physicians in our study said that providing care to and helping patients from different cultural backgrounds than their own, particularly new immigrants and members of marginalized groups, was especially rewarding. International medical graduate FPs appreciated the complexities of the Canadian health care system and found it fulfilling to help such patients navigate them. They enjoyed advocating on behalf of patients and experienced a sense of gratitude from these individuals for their services.
[It is nice to] be able to feel that you’re helping, especially those who are either at a disadvantage or have needs, and that they appreciate that you’re doing your best to understand them. (Interview 1; C-IMG, male)
I kind of empower them.… [M]ost patients I end up seeing are very quiet, weak, and shy, and they will do what they’re told, but if they don’t ask questions, or if they don’t believe what they’re doing is correct, they may not even do it in the first place.... [So, I end up] being more of an advocate and showing them and their families how [to proceed]. (Interview 7; I-IMG, male)
It is important to note that in the latter quotation, from interview 7, the participant’s description of patients as “weak” may be stigmatizing. Although the participant’s intention appeared to have been to highlight the important role of patient advocacy, his chosen language may reflect his perceptions of patients from different cultural backgrounds and may not be an accurate representation of these people.
Challenges of caring for patients from different cultural backgrounds
International medical graduate FPs recalled challenges in 3 key areas when providing care to patients from different cultural backgrounds than their own: language barriers, longer patient visits, and a perceived lack of acceptance among patients of physicians’ medical expertise and legitimacy.
Language barriers. Almost all IMG FPs interviewed said that language barriers posed substantial challenges when providing care to patients who did not speak the same language as the physician. In cases where patients’ first languages were not English, physicians believed those patients may have struggled to understand them and may not have comprehended what was expected of them. Physicians expressed uncertainty about patients’ levels of understanding regarding medical advice and treatment recommendations provided.
I have to have interpreters to make sure the message is received clearly and there’s no confusion. Otherwise, it’s dubious.… [I]f they don’t understand or I don’t understand them, there’s a communication breakdown. (Interview 11; I-IMG, male)
One challenge would be if there is a language barrier, that I cannot communicate. To just understand what exactly they want me to do and what exactly I can provide them. (Interview 10; I-IMG, male)
Longer patient visits. Some physicians indicated they experienced longer appointments with some patients from cultural backgrounds different from their own. They attributed this to lacking a common language, having a different understanding of the nature of disease and illness, and the complexity of the patient problem being addressed.
It takes more explanation, it takes more time to educate them. (Interview 11; I-IMG, male)
People from other parts of the world, sometimes you have to explain what you mean by strep throat, and sometimes you have to explain in detail that there are viruses, and there are bacteria, and there are other causes. So, I feel the education level also affects, apart from communication … how long your visit is going to be and how much time they want to take. (Interview 13; I-IMG, female)
In addition, physicians noted that they needed more time initially to build rapport with patients from different cultural backgrounds, and they acknowledged that more time together was needed to gain the trust required when disclosing intimate health details.
[W]hen the cultural background is totally different from Canadian … then I actually have to spend time to figure out first what’s the cultural expectation, and then find the right approach. (Interview 18; I-IMG, female)
It takes longer to establish the trust I need in my practice to show that I have all the time in the universe for that, that I’m there for them and that I’ll be patient and respectful [of] their wishes. (Interview 18; I-IMG, female)
Discrimination and lack of acceptance. Some IMG FPs believed they had been discriminated against based on patients’ perceptions of the physicians’ cultural backgrounds. For example, IMG FPs expressed concern that their medical education and training qualifications were being questioned by patients from different cultural backgrounds based on cultural differences. International medical graduate FPs reiterated in interviews that they had completed the same family medicine residency program as Canadian family physicians. Still, visible differences in their cultural identity led to unfair assumptions about their capabilities as practising physicians in Canada.
[I]n ethnic backgrounds that are different than mine … there is a bit of prejudice, a little bit of underlying racism.… There’s a bit of hesitation when you see an East Asian physician sometimes when it comes to other ethnic groups that you have to immediately kind of dissolve … when you open your mouth, and that’s when a decision is made by the patient whether or not they trust you or understand you or are going to take to you immediately. Otherwise, it might take a lot of convincing. (Interview 16; I-IMG, female)
I get the odd person that will walk in, take a look at me, hang around for a few minutes and then just walk out without even saying why they’re walking out. Yes, that’s happened a few times. (Interview 17; I-IMG, female)
[I]n other cultures, it may take slightly more time [addressing] a lot of the trust issues. Because they may have more prejudice and as a result of that you’ve got to overcome that, or they may think that you may not be as smart or as diligent as someone from their own culture would be. (Interview 7; I-IMG, male)
DISCUSSION
To our knowledge, this is the first qualitative study of IMG FPs’ experiences with providing cross-cultural patient care in a Canadian context. While physicians find it rewarding to learn about their patients’ different cultural backgrounds and to advocate on patients’ behalf, language barriers, perceived discrimination by patients, and skepticism about the legitimacy of IMG FPs’ medical credentials were identified as challenges. The rewarding aspects of providing cross-cultural care contribute to physician learning, job satisfaction, and provision of clinical patient care. However, the challenges impede doctor-patient communication and may compromise doctor-patient relationships.
Our findings related to the perceived discrimination experienced by IMGs are not unique. A survey conducted in the United States found that IMGs were more likely to experience discrimination than US medical graduates; however, the difference was not statistically significant.16 In Canada, a previous survey of Alberta graduates revealed a significantly greater proportion of IMGs than Canadian family medicine graduates perceived they had been subject to intimidation, harassment, and discrimination that was attributed to culture and ethnicity (P<.001) and to language (P=.02).17 Our qualitative study identifies an additional perceived type of discrimination based on foreign education backgrounds. Even though all the IMGs in our study completed residency training in Canada and passed Canadian medical licensing examinations, the perceived discrimination appears to have been based on perceptions that education credentials obtained outside of Canada are somewhat inferior to Canadian medical education. Family medicine residency programs would benefit from having more IMGs participate in teaching, as they could help learners be more aware of cultural challenges they may face.18
In our study, IMG FPs had diverse perspectives on the amount of time spent on appointments when caring for patients from different cultural backgrounds than their own. Some physicians attributed shorter visits to patients having strong health literacy and English language skills, thus requiring less patient education during the visit. Those who believed that patient visits took longer attributed this to overcoming language barriers, requiring more time to develop a mutual understanding of patients’ concerns, and needing more time to build rapport and trust. Language barriers have been shown to affect access to health care,19,20 have been reported as causing poorer quality of care and treatment delays,21,22 and have been shown to require more time and resources for visits.22 Duration of patient visits can vary depending on the complexity of the medical issue, the degree of social interaction between the doctor and the patient, and the amount of time the physician or patient has for the appointment. Physicians should consider lengthening initial patient visits with patients from different cultural backgrounds if they are experiencing cultural barriers that affect quality of care. Investing more time up front may enable physicians to build the trust and rapport they need to ensure that patients’ needs are met and to potentially avoid adverse effects associated with mistrust and language barriers.
Limitations
This study was not without limitations. While the IMG participants were from a broad range of cultural backgrounds, not all cultural identities were included in this study. In addition, the study was limited to IMG FPs practising in metropolitan areas and did not include those in rural practice or IMGs in other specialties. Given that IMG physicians make up a substantial proportion of the physician supply in rural areas of Canada, a similar study of rural IMG physicians is warranted. Future studies exploring patients’ experiences receiving care from physicians from different cultural backgrounds would provide alternative perspectives to the current findings.
Conclusion
This study exploring IMG FPs’ experiences in providing care to culturally diverse patient populations revealed a range of rewards and challenges. Rewards included working with diverse cross-cultural patient populations, enabling physicians to learn about new cultures and patients’ varied views of health and illness. Physicians also found it gratifying to advocate for patients who struggle to navigate the health care system. International medical graduates also experienced language barriers, which they attributed to speaking English as a second language and to other issues, including patient education levels and differences in cultural viewpoints. Some IMGs experienced a lack of acceptance from patients based on the physicians’ cultural identities and professional qualifications. As rates of immigration and multiculturalism continue to increase worldwide, the need and demand for cultural humility and cultural competence training will also increase for all medical professionals, whether they have trained locally or abroad.
Acknowledgment
Financial support for this research was provided by the Dr Scott H. McLeod Family Medicine Memorial Fund.
Notes
Editor’s key points
▸ International medical graduates compose approximately 25% of the physician workforce in Canada and are instrumental in providing health care to the country’s multicultural population.
▸ International medical graduate FPs find it rewarding to advocate for patients of different cultural backgrounds, particularly when helping patients who are recent immigrants navigate the health care system.
▸ International medical graduate FPs perceived discrimination from patients based on cultural differences and skepticism about their medical education credentials.
▸ This research highlights the need for cultural humility and cultural competency training among FPs in Canada.
Points de repère du rédacteur
▸ Les diplômés en médecine de l’étranger représentent environ 25 % des effectifs de médecins au Canada; ils contribuent à la prestation des soins de santé à la population multiculturelle du pays.
▸ Les diplômés en médecine familiale de l’étranger trouvent qu’il est gratifiant de défendre les intérêts de patients venant de différentes origines culturelles, surtout lorsqu’ils aident des patients nouvellement immigrés à naviguer dans le système de santé.
▸ Les diplômés en médecine familiale de l’étranger ont perçu de la discrimination fondée sur des différences culturelles de la part de patients et du scepticisme entourant leurs qualifications médicales.
▸ Ces recherches mettent en évidence la nécessité d’une humilité culturelle et d’une formation en adaptation culturelle chez les MF au Canada.
Footnotes
Contributors
Dr Sudha Koppula, Olga Szafran, Kimberley Duerksen, and Dr Martina Barton made substantial contributions to the conception and design of the work. Dr Jacqueline Torti contributed to the acquisition of data. Dr Jacqueline Torti, Dr Sudha Koppula, Olga Szafran, and Kimberley Duerksen contributed to the data analysis and all authors contributed to the interpretation of the data. Dr Jacqueline Torti drafted the work and substantively revised it with Olga Szafran. All authors read and approved the final manuscript.
Competing interests
None declared
This article has been peer reviewed.
Cet article a fait l’objet d’une révision par des pairs.
- Copyright © 2023 the College of Family Physicians of Canada
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