According to statistics from the American Medical Association, 42 percent of all general psychiatry residents are international medical graduates (IMGs). Additional AMA data show that there are significant cultural differences between international medical graduates and the patients they serve, according to Gabrielle F. Beaubrun, M.D., chief resident at the King-Drew Medical Center in Los Angeles, an APA/AstraZeneca Fellow, and an American College of Psychiatrists Laughlin Fellow.

"The research has shown that IMGs practice more frequently in public psychiatry and, as a result, serve more ethnically diverse populations. This gives rise to the need for culturally competent training for IMGs practicing in these settings," commented Beaubrun.

Richard Balon, M.D., APA Assembly representative for IMGs, and Rodrigo A. Muñoz, M.D., former APA president, reported in 1996 that IMGs were overrepresented in city, county, and state psychiatric hospitals when compared with graduates of U.S. medical schools—10.7 percent to 5.2 percent, respectively. IMGs were also underrepresented in solo and group office practices and medical schools or universities.

However, there is more to understanding cultural diversity than a person’s race and ethnicity, according to Beaubrun. She pointed out that "gender, age, sexual orientation, spiritual beliefs, social classes, and physical disabilities are part of one’s culture, too."

"There can be differences from culture to culture in behavioral norms," commented Beaubrun, "and it is so important for patients to be able to express themselves freely without having to wonder if their doctor will understand them."

Since eye contact or a handshake can carry different connotations from one culture to another, it is important that psychiatrists be aware of those differences, said Beaubrun.

"In Pakistan, for instance, it may be considered inappropriate for a man and woman to shake hands. In the U.S., however, some people might consider others rude if they don’t extend their hand." Also, Beaubrun added, while assertiveness in women is valued in the U.S., it is discouraged in some other countries, so it is important for foreign-born women doctors to learn to be assertive in group situations.

"People may also not realize that there are differences in medical school training itself with respect to the doctor-patient relationship and patient autonomy," said Beaubrun.

In many parts of the world, she explained, medicine operates under a paternalistic structure, in which the patient defers to the physician. In addition, foreign-born medical graduates may need to adjust to the importance of patient autonomy in the U.S.

Cultural confusion is not the only problem that many of these doctors must contend with. Foreign-born medical graduates "are also facing personal issues," said Beaubrun. "While adapting to the changing cultural context in his or her professional life, the graduate may also be dealing with personal losses."

Examples of such hardships endured by the foreign-born medical graduate include leaving family behind to come to the U.S., fears of rejection, loss of self-esteem, and an identity crisis as a minority physician, not to mention hefty financial woes, which may add to any stress in the graduate’s life.

Barriers to cross-cultural competency are not always visible, in Beaubrun’s view. "In orienting to culture, the most difficult thing is perceiving the hidden agenda of racism in America," she stressed. What constitutes racism is "not listed in a textbook, but instead [is] learned and assimilated."

However, Beaubrun does see a light at the end of the tunnel. Recently, the Residency Review Committee in Psychiatry announced several new training requirements for residents in psychiatry, including an updated requirement that sociocultural factors must be addressed in all aspects of training.

"I think the latest addition to the Accreditation Council for Graduate Medical Education guidelines for residency training is very encouraging; however, I am not convinced that changes on paper always translate into real learning for residents," she told Psychiatric News. "I wonder, who will train the trainers? Good cross-cultural training needs to come out of genuine caring and interest on the part of the instructor."

As a minority resident herself, Beaubrun has received the education of a lifetime—not necessarily from her training in the West Indies, but from her patients. As a resident working in inner-city South Central Los Angeles, she expected to face race-related cultural issues, but found herself initially unprepared for what she encountered.

"Understanding what it means to live in the projects or hear gunfire on a daily basis and what that does to the psyche has proved to be essential to my understanding of the different presentations of psychiatric illness in my patients," she observed.

Beaubrun told Psychiatric News that when taking a basic history, she has often asked patients how a close relative had died and received a two-word response: "drive by."

"Finding that beneath this simple, nonchalant phrase lay so much pain, anger, and fear was like opening a new door to understanding my patients," said Beaubrun.

This type of interaction, she added, highlights the fact that there is so much more to culture than race or language, and this has been one of the most important lessons she has learned so far.