Japanese International Medical Graduates and the United States clinical training experience: Challenges abroad and methods to overcome them

Abstract Introduction Due to the large language and cultural distances between Japan and the US compared to many countries, Japanese International Medical Graduates (IMGs) may have a different US training experience, including more stress, than many IMGs. We examined the US clinical training experience for Japanese IMGs, including the challenges encountered, how those challenges are overcome, and the benefits of US training. Methods We performed individual semistructured interviews with 35 purposively sampled Japanese IMGs who had completed US clinical training. Exploratory thematic analysis was conducted using iterative data collection and constant comparison. Results All participants reported high personal growth and that US clinical training was worth the sacrifices. Commonly fatigue was lower than during Japanese residency. Participants explained medical practice and local culture associated challenges that aligned with literature on US graduates and other IMGs. By contrast, nearly all participants reported that English communication was very challenging, and described specific language related struggles and methods to help overcome them. Communication struggles were contextualized within an American training culture that values verbal assertiveness. Self‐esteem varied among participants and, for some participants, improved with confidence in communication. Several participants reported depression and other mental illness. The training environment varied among residency programs. Conclusions Japanese IMGs who completed US training report that it was worth it, but describe significant language and culture related struggles and effects on mental health. Further research should address which Japanese IMGs are most likely to struggle, how this will transpire, and how to optimize the US clinical training experience.


| INTRODUC TI ON
To some extent, in their pursuit of United States (US) clinical training, all international medical graduates (IMGs) share personal sacrifices including time and expenses for the US Medical Licensing Examinations and application process, and the opportunity costs of other activities and personal relationships. 1,2 Within the literature, the elaborated portrait of this endeavor explains IMG anticipation of improved salary, career opportunities, and social conditions, intertwined with cultures of migration within their home medical institutions. [2][3][4][5][6] However, the literature, while frequently examining IMG ethnic subsets individually, is shaped by the predominance of IMGs hailing from lower income nations and a medical school education conducted in English. 3 By contrast, Japanese IMGs are distinguished from most IMGs by a greater challenge to achieve English proficiency and by the primary incentives of a personal challenge to become a more accomplished doctor and desire to improve medical education back in Japan. 7 Literature examining the IMG experience during clinical training in the host country commonly addresses IMGs of different ethnic backgrounds collectively and identifies struggles frequently with the unfamiliar healthcare system, regional accents and vernacular, and incongruences with local values and their own backgrounds. [8][9][10][11] At the same time, the literature finds that compared to fellow American resident physicians, IMGs experience lower fatigue, higher self-esteem, and higher personal growth. 12 Within these studies, Japanese IMGs are not represented.
In consideration of the steeper English language barrier and nuanced cultural differences, 13,14 the Japanese trainee relationship to the US experience may not match common IMG themes. Potentially relevant aspects of American graduate medical education (GME) contrasting Japan include strict duty hours, and regimented progressive responsibility and conditional independence intertwined with written examinations and evaluations during and upon completion of training. 15 The underlying objectives are to assure safety for all patients and competence of all physicians. 16 An important consequence is that the American system mandates remediation programs for trainees who demonstrate unsatisfactory performance, and ultimately dismissal of trainees who fail to satisfactorily improve. 15 Attrition rates during residency are higher among IMGs than US graduates. 17 Such practice contrasts Japan where long-term employment is generally assured upon entrance to a training institution; in turn, for Japanese IMGs, US clinical training may incur significant stress.
Individual Japanese IMGs have written about their US clinical training experiences, 18 but a systematic study is lacking. In this study, we examine the US clinical training experience for Japanese IMGs, including the challenges encountered and where possible, how those challenges are overcome, and whether the US training was worth the sacrifices made. We hope to assist interested Japanese and enhance understanding of international medical migration through the lens of this atypical population.

| ME THODS
This report is complemented by a separate report from the same study that examines challenges for Japanese physicians in their pursuit of US clinical training. 19 We used identical participants and methods, and collected and analyzed the data simultaneously.

| Clinical training context-the American Graduate Medical Education system
In the United States, the American College of Graduate Medical Education (ACGME) oversees GME for nearly all clinical specialties, including the duration and content of training, with input from specialty professional societies. 20 Entry into medical care for most patients and clinical scenarios is via primary care, 21 and accordingly, the primary care fields of internal medicine, family medicine, and pediatrics are allotted the most residency positions. 22 Similar to the evolving Japanese clinical training structure, 23 a three-year training program in these fields must generally be completed prior to subspecialty fellowship which lasts an additional 1-3 years. A comparable organization exists in surgical fields whereby general surgery residency is a foundational step to specialized fellowship in some disciplines. Completion of each residency or fellowship training program is followed by a rigorous board certification examination. 20 Board certification is increasingly required by physician employers and insurance companies. 24

| Study approach
Our study employed constructivist exploratory thematic analysis, 25,26 given our intention to understand the US clinical training experience for Japanese IMGs. Constructivist methodology recognizes the relationship of researchers' prior knowledge to data collection and interpretation.

| Participant sampling
Because no comprehensive database of Japanese IMGs was available, potential participants were identified by (a) asking participants to suggest other potential participants, optimally with experiences contrasting their own, and (b) requesting names of Japanese graduates from training programs in the United States and Japan who had educated Japanese IMGs. Graduation from Japanese medical schools and completion of US clinical training within one to fifteen years at time of interview were required for participation. Also, we targeted approximately 50% returnees to Japan and 50% practitioners in the United States. We selected these parameters because separate work examines experiences after US training. Each participant was solicited via email with a description of the study and provided informed consent. Thirty-five of 39 contacted physicians agreed to participate. The Institutional Review Board at the University of Pittsburgh Medical Center approved the study.

| Data collection and analysis
We conducted individual semi-structured interviews from February 2013 until October 2015 in person when feasible, and otherwise via phone or Skype. Interviews were conducted in English, digitally recorded, and transcribed verbatim by a professional transcriptionist.
We used open coding methodology to independently analyze the transcripts, and through discussion created an initial codebook. To improve readability of quotations, we edited the grammar and, where thoughts were not verbalized, added bracketed text. For the purpose of quotations, participants are numbered 1-35. At the time of the interview, participants 1-19 and 20-35 were working in Japan and the United States, respectively.

| English communication
Foremost, nearly all participants reported that English was a major challenge. Communicating at the pace of natural conversation on diverse topics and sometimes with strong accents and/or local vernacular was significantly different from participants' prior experiences in relatively controlled scenarios. As Participant 8 succinctly explains, "[Upon beginning US residency] I thought I knew some English language, but I did not." Challenges included communication, in general and in specific situations ( Participants did not perceive discrimination from coworkers or patients for being Japanese but did report infrequent tension during interactions that they attributed to their language barrier.
Overall, people were really supportive of Japanese physicians. Sometimes Americans had [a negative impression due to my] English communication skills, and the really strong accent I had.

| American medical practice and local culture
Participants described cultural differences from Japan (Table 2). Some issues were specific to medical practice. Many participants reported that a strictly enforced shift schedule with frequent sign-outs resulted in initial difficulty completing patient care tasks including documentation more detailed than in Japan, and internal ethical struggles when they were unable to be nearby for patients such as during terminal illness. Relatedly, participants explained that the American model of care prioritizes discharge sooner than in Japan and that collaboration among physicians representing numerous disciplines combined with extensive ancillary support accelerates patient management. Patient care decision making was rapid, and communication among healthcare professionals was more extensive than in Japan. Participants noted that decision making was complicated by the American multi-payer health insurance system, whereby financial barriers to care may arise depending on the patient's insurance provider and policy. Other challenges-ethical stances in certain situations, the doctor-patient relationship, excessive opioid analgesics, and patients representing diverse ethnicities and socioeconomic extremes-were more intertwined with American national cultural differences from Japan. Additionally, a few participants lamented that the American diet was less palatable than back home.

Communication with patients
In Japan, the English we are exposed to is very easy to understand, but in the States, the patients speak with a variety of accents… That was hard. (3) I still don't understand some colloquialisms… But patients understand I'm a foreigner, so I always try to ask exactly what they mean, by, [asking] say, A, B, or C. (24) Emotionally delicate situations The patient was a 15 year-old girl, and her mother was in the room. The patient was sexually active, and it seemed like she wanted to discuss it with me. I asked the mother to step out of the room, and she got mad. She actually said, "OK, I'll leave." But about ten minutes later, she returned, yelling at me "Why did you make me step out of the room?! I'm her mother! I have a right to know everything about my daughter!" And I was like, "That was my fault that I said that, but she has the right to talk to me individually, and you have to leave the room." And she left the room but later asked to talk to the director.   disorder…. I was placed on one-month medical leave. (16) No participants reported clinical incompetence as the source of such struggles.

| Overcoming challenges during US residency
To cope with their primary stressor, English communication, participants most commonly described trying to compensate by enhancing aspects of work they could better control, such as medical knowledge and professionalism.
Additionally, some participants described specific methods they used to overcome English-related challenges including an attitudinal shift toward accepting one's linguistic mistakes and asking for help, using nonverbal communication, using local students to help interpret, embracing one's identity as a trainee, and speech therapy. Table 4 contains representative quotes.
In response to the cultural differences, several participants explained the need for an adaptive attitude.
Similarly, some participants described the importance of adopting local practices.
I would steal styles from different people to make my own system.

| Fatigue, self-esteem, and personal growth
Participants were surveyed about their levels of fatigue, self-esteem, and personal growth during US clinical training. Most participants reported lower fatigue than during Japanese residency due to work-hour limitations. Personal circumstances, such as parenthood, contributed to cases of increased fatigue. Participants evenly reported their self-esteem in the United States as lower, similar, or higher than during Japanese training (Table 5). Factors lowering self-esteem were the struggles with English, the foreign context, and regression to intern status described above.
Participants with high self-esteem tended to demonstrate confidence in English and feeling well-prepared for US residency, for example in cases of prior US Naval Hospital internship. Some participants explained low self-esteem during the first one to two years of struggles that rose with improved English communication, comfort with the American system, work performance recognition from colleagues, and associated confidence. All participants reported high personal growth during US training. Contributors included deepened understanding of a new culture, and professional and personal accomplishments.

| Benefit of clinical training in the United States
All participants endorsed that in hindsight they would still pursue Regarding specific content of US training, many participants em- (1)

| CON CLUS IONS
Pursuit of US clinical training involves tremendous sacrifice, and Japanese IMGs who completed it report that it was worth it.
Simultaneously, during US clinical training, these Japanese IMGs reported significant challenges and struggles. Some challenges reflect facets of American medical care, graduate medical education, and cultural and socioeconomic diversity that align with experiences of US graduates and other IMGs. Struggles more specific to Japanese IMGs were rooted in communication difficulties compounded by the Western culture valuing verbal assertiveness. Some Japanese IMGs experienced depression and other mental health diagnoses, and dismissal of Japanese IMGs from US training programs was mentioned.
Topics for further examination include which Japanese IMGs are most likely to struggle, how this will transpire, and how to optimize the US clinical training experience.

ACK N OWLED G EM ENTS
We greatly appreciate the time and thoughtful comments contributed by all participants, and financial support from the Shadyside

CO N FLI C T O F I NTE R E S T S
The authors have stated explicitly that there are no conflicts of interest in connection with this article.