1. Teaching Behavior Change Strategies to Residents from Other Cultures Sue Jarquin, MA Jeannie Sperry, PhD Scott Fields, PhD Kimberly Foley, PhD West Virginia University Family Medicine

2. Objectives Increase awareness of differences between International Medical Graduates (IMGs) and US graduates regarding training in behavioral science and chronic illness Increase awareness of differences between International Medical Graduates (IMGs) and US graduates regarding training in behavioral science and chronic illness Identify ways to assess and address knowledge differences Identify ways to assess and address knowledge differences Enhance teaching of behavioral change strategies to IMGs to enhance comprehensive care of chronic illness Enhance teaching of behavioral change strategies to IMGs to enhance comprehensive care of chronic illness

3. Your experiences?

4. Common problems: – Resident remains standing – Closed-ended questions – Rigid, unyielding agenda – Diagnostic rigidity – Focus on only “medical” problems – Difficulty initiating rapport – Difficulty maintaining rapport

5. Common problems _ Language barriers _ Language barriers – Talking too fast – Minimal collaboration – Report feeling “singled out” by video – Have to be “certain” of plan – Occasional disrespect toward female faculty

6. In what ways are IMGs different from USMGs? A great deal of variability in education, training, and experience A great deal of variability in education, training, and experience Top 5 countries of medical education for IMGs in 2009 India 20.7% India 20.7% Philippines 8.3% Philippines 8.3% Mexico 5.6% Mexico 5.6% Pakistan 4.9% Pakistan 4.9% Dominican Republic 3.2% Dominican Republic 3.2% –AMA, 2010

7. IMGs and Primary Care Top 5 IMG specialties in 2009 Internal Medicine 37% Psychiatry 32% Anesthesiology 28% Pediatrics 28% Family Medicine 27% AMA, 2010

8. IMGs and Primary Care 941,304 physicians in the U.S. 941,304 physicians in the U.S. 243,457 (26%) IMGs 243,457 (26%) IMGs 58% of IMGs are in primary care 58% of IMGs are in primary care More often in Primary Care due to USMGs going for specialty More often in Primary Care due to USMGs going for specialty More often in shortage areas and public sector More often in shortage areas and public sector Treat higher proportion of minorities Treat higher proportion of minorities Supply 2/3 of care to the poor Supply 2/3 of care to the poor

9. Teaching prevention and care of chronic illness: should we adapt for IMGs? Patient Education? Patient Education? Behavioral Change? Behavioral Change? Team Approach? Team Approach? Psychosocial Interviewing? Psychosocial Interviewing? Use of Mind-Body Interventions? Use of Mind-Body Interventions? Integration of Mental Health? Integration of Mental Health? Doctor-Patient Relationship? Doctor-Patient Relationship?

10. Patient education? Chronic disease interventions that positively affect patient well-being necessarily include systematic efforts to increase patients’ knowledge, skills, and confidence in their ability to manage a health condition Wagner et al., 2001 Chronic disease interventions that positively affect patient well-being necessarily include systematic efforts to increase patients’ knowledge, skills, and confidence in their ability to manage a health condition Wagner et al., 2001 Yet, in many of the countries in which IMGs attend medical school an emphasis on patient education is ignored due to the low literacy levels of the poor patients who access medical care in teaching hospitals Singhal, & Ramakrishnan, 2004 Yet, in many of the countries in which IMGs attend medical school an emphasis on patient education is ignored due to the low literacy levels of the poor patients who access medical care in teaching hospitals Singhal, & Ramakrishnan, 2004

11. Behavioral change? Many IMGs receive minimal if any instruction in communication skills Singhal, & Ramakrishnan 2004 Many IMGs receive minimal if any instruction in communication skills Singhal, & Ramakrishnan 2004 Hierarchical expectations: IMGs may not have experience treating patients who present as uncooperative and non-compliant Cole-Kelly, 1994 Hierarchical expectations: IMGs may not have experience treating patients who present as uncooperative and non-compliant Cole-Kelly, 1994 Importance of the physician-patient relationship as it relates to the promotion of behavior change may not have been addressed in the training of some IMGs Searight & Gafford, 2006 Importance of the physician-patient relationship as it relates to the promotion of behavior change may not have been addressed in the training of some IMGs Searight & Gafford, 2006

12. Team approach? Medical system in other countries often hierarchical, authoritarian, without continuity. Medical system in other countries often hierarchical, authoritarian, without continuity. Less likely to expect to learn from physician extenders Less likely to expect to learn from physician extenders IMGs may have less exposure to specialists during medical school, so IMGs may have less exposure to specialists during medical school, so lacked the skills needed to access specialists efficiently and the assertiveness needed to engage specialists Lockyer et al 2010 lacked the skills needed to access specialists efficiently and the assertiveness needed to engage specialists Lockyer et al 2010 less inclined to collaborate with a behavioral health provider when treating a patient with a chronic disease less inclined to collaborate with a behavioral health provider when treating a patient with a chronic disease

13. Psychosocial Interviewing? Often IMGs receive a minimal amount of instruction on the impact of psychosocial factors on health and influence on chronic disease Often IMGs receive a minimal amount of instruction on the impact of psychosocial factors on health and influence on chronic disease IMGs may refrain from inquiring due to concerns about insulting or offending the patient. IMGs may refrain from inquiring due to concerns about insulting or offending the patient. IMGs may lack comfort and skill in psychosocial interviewing: they may have been taught that questions about anything but chief complaint are inappropriate and invasive Searight & Gafford, 2006 IMGs may lack comfort and skill in psychosocial interviewing: they may have been taught that questions about anything but chief complaint are inappropriate and invasive Searight & Gafford, 2006

14. Use of Mind-Body Interventions? The most effective chronic disease management programs include medical interventions as well as psychosocial and behavioral interventions The most effective chronic disease management programs include medical interventions as well as psychosocial and behavioral interventions Cummings et al., 2005 Cummings et al., 2005 The National Institute of Health defines behavioral/mind-body interventions as techniques designed to facilitate the mind’s capacity to affect bodily functions and symptoms Astin et al., 2003 The National Institute of Health defines behavioral/mind-body interventions as techniques designed to facilitate the mind’s capacity to affect bodily functions and symptoms Astin et al., 2003 Many IMGs may have more exposure to these techniques in native countries but disinclined to promote them as they are perceived as less technological Many IMGs may have more exposure to these techniques in native countries but disinclined to promote them as they are perceived as less technological

15. Integration of Mental Health? Many mental health conditions (e.g., anxiety and depressive disorders) treated in U.S. primary care are not addressed by PCPs in IMGs’ home countries. Many mental health conditions (e.g., anxiety and depressive disorders) treated in U.S. primary care are not addressed by PCPs in IMGs’ home countries. Mental health issues in some countries are not seen as medical problems requiring intervention, but rather unpleasant, but normal parts of life. Mental health issues in some countries are not seen as medical problems requiring intervention, but rather unpleasant, but normal parts of life. ( Medicalization of normal life stresses) ( Medicalization of normal life stresses) Emotions are not talked about, so difficulty reading emotional body language and English vocabulary for emotions Emotions are not talked about, so difficulty reading emotional body language and English vocabulary for emotions

16. Integration of Mental Health: Children? Childhood is viewed differently in many countries Childhood is viewed differently in many countries – In the US children are expected to focus on education, playing, and maturing – In other countries, children have additional responsibilities towards the family Children are treated as “mini-adults” Children are treated as “mini-adults” Child behavior difficulties are viewed as a lack of will for the child or a lack of discipline in the family Child behavior difficulties are viewed as a lack of will for the child or a lack of discipline in the family May perceive US family life as isolated and lacking in resources for children May perceive US family life as isolated and lacking in resources for children

17. Integration of Mental Health: Children? Differences in expectations for children Differences in expectations for children – Unfamiliar with medical and psychological difficulties faced by US children EX: ADHD EX: ADHD – May be unfamiliar with state intervention in families and requirements for reporting to agencies Differences in verbal communication and non-verbal interactions Differences in verbal communication and non-verbal interactions Differences in developing rapport Differences in developing rapport

18. Doctor-patient relationship? Physicians in many IMGs’ home countries care for -60 or more patients a day -Not privately -Only acute visits -Tertiary care -Minimal continuity -Confidentiality is an issue as is a trusting doctor-patient relationship. Searight and Gafford, 2006 Searight and Gafford, 2006

19. Doctor-patient relationship? US: Patient autonomy and medico-legal system reigns US: Patient autonomy and medico-legal system reigns IMGs may have observed: The doctor’s job is to tell the patient what to do, and IMGs may have observed: The doctor’s job is to tell the patient what to do, and Doctors should know what to do. Doctors should know what to do. IMGs may be unprepared to treat inquisitive U.S. patients IMGs may be unprepared to treat inquisitive U.S. patients Patients’ in IMGs’ home countries may not ask questions about treatment options or doubt physicians’ authority. Searight and Gafford, 2006 Patients’ in IMGs’ home countries may not ask questions about treatment options or doubt physicians’ authority. Searight and Gafford, 2006

20. Some additional issues in teaching specific health behavior change skills to IMGs…

21. Teaching Health Behavior: Nutrition Importance of treating leprosy vs treating “persons who are eating themselves to death” Importance of treating leprosy vs treating “persons who are eating themselves to death” Lack of personal experience in cooking: Lack of personal experience in cooking: – Servants – Measuring cup Foods are different Foods are different Freezers, families, etc Freezers, families, etc

22. Teaching Health Behavior: Exercise Survival in home countries –not wanting excess calorie loss Survival in home countries –not wanting excess calorie loss Cultural aspects of exercise re males/females in gym Cultural aspects of exercise re males/females in gym Lack of personal experience in exercise: Lack of personal experience in exercise: – Previously walked: Have to get cars here

23. Teaching Health Behavior: Substance Use May be unfamiliar with disease model of addiction (medicalization of social ill) May be unfamiliar with disease model of addiction (medicalization of social ill) May be unprepared to deal with drug-seeking in medical clinic May be unprepared to deal with drug-seeking in medical clinic

24. Teaching Health Behavior: Stress Reduction/Mind-Body Techniques May be unfamiliar with science behind use May be unfamiliar with science behind use May be uncomfortable with practices often promoted by other “healers” in society May be uncomfortable with practices often promoted by other “healers” in society

25. What are you doing to help teach health behavior change? Additional/Different USG vs IMG? Additional/Different USG vs IMG? Assess attitudes/skills earlier? Assess attitudes/skills earlier? Advance behavioral science curriculum for IMGs? Advance behavioral science curriculum for IMGs? Provide specific wording on cue cards? Provide specific wording on cue cards? Offer earlier orientation? Offer earlier orientation? Emphasize personal use? Emphasize personal use? ?? ??

26. What we are doing: Orientation Orientation – Buddy system – ½ day retreat with globe, names, family here? – Ethnic potluck – Communication OSCE in Sim Lab – 2-hour workshop with video review and observation checklists (POVE via Larry Mauksch) – Chief resident helps with workshops, etc

27. Modeling Modeling – All residents, including IMGs, get to watch their peers do interviews in simulation center. Observing Observing – All residents have attendings, sometimes the behavioral health consultant, do interviews with them and provide feedback shortly thereafter. – Greeting, positioning, open-ended questions – Earlier and more frequent observation Didactics Didactics – Lectures are provided, especially in first year to model interpersonal and interviewing skills Web assignments (doc.com, etc) prn Web assignments (doc.com, etc) prn

28. Resources IMG Acculturation Portal Acculturation Program of the Educational Commission for Foreign Medical Graduates (ECFMG) re introducing IMGs to American medicine, American GME and living and working in the United States IMG Acculturation Portal Acculturation Program of the Educational Commission for Foreign Medical Graduates (ECFMG) re introducing IMGs to American medicine, American GME and living and working in the United States Website and IMG night Website and IMG night Materials the ECFMG are interested in www.ecfmg.org/acculturation Materials the ECFMG are interested in www.ecfmg.org/acculturation http://www.ecfmg.org/acculturation

29. More to come… Dissertation 2011-2012 Sue Jarquin Dissertation 2011-2012 Sue Jarquin Difference between USMG, IMG, US IMG in behavioral science training re chronic illness Difference between USMG, IMG, US IMG in behavioral science training re chronic illness Email re survey monkey to listserv Email re survey monkey to listserv If not on listserv, please leave email address If not on listserv, please leave email address Will share results with listserv and emails Will share results with listserv and emails

30. Thank you for your participation! sperryj@wvuhealthcare.com scott.fields@camc.org sjarquin@mix.wvu.edu foleyki@wvuhealthcare.comperryj@wvuhealthcare.comcott.fields@camc.org sjarquin@mix.wvu.edu