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Cross-cultural code-switching brings up challenges for international doctors in Aotearoa, which might affect their ability to practise effectively.

New Zealand’s health system must improve cultural integration practices for international doctors or risk losing them, a University of Otago study argues.

Lead author Dr Mariska Mannes, who completed her PhD through the Division of Humanities, says the country relies on international medical graduates (IMGs) to fill critically important roles, but they struggle with cross-cultural code-switching.

“Many of them leave New Zealand jobs because they experience stress, loss of identity or loss of confidence brought on by the struggle to adjust culturally,” she says.

“Cultural differences can impact on their ability to practise effectively and on their wellbeing – it is critical to support not only their integration into medical practice but also their cultural integration, to improve retention rates.”

Despite the fact international doctors come with a wealth of knowledge, they are expected to fit in, Dr Mannes says they are often given the message: ’You are in New Zealand now, do it our way’.

The study, published in BMC Medical Education, interviewed international specialists, registrars and general practitioners from the United Kingdom, the United States, South Africa, South America and South and Southeast Asia.

It reveals psychological challenges of cross-cultural code-switching due to professional and cultural differences might affect IMGs’ ability to practise effectively and influence whether they remain in New Zealand.

Study participants had all been qualified for two years before arriving the country, and had been practising in New Zealand from at least one year, to more than 10 years.

One participant reported their frustration at the need to ‘sugar coat’ information, which made them feel inauthentic.

“Where I come from, the dryer you are, the better you are, because you are not hiding anything.

“Here you must sugar coat, it’s like a new language so I struggle, I try to copy but then I don’t know if it is the right occasion.”

Another reported how difficult it was to keep up a code-switch and shared how they automatically reverted to their ingrained cultural behaviour in stressful situations, leading to complaints.

“It’s exhausting! . . . When I’m stressed or exhausted or tired or sleep deprived or all of the above, I resort back to my normal behaviour . . . are you needing me to change fundamentally who I am, which means that I can’t carry on with that façade and then I am not true to myself.”

Some IMGs noticed a difference in the way Māori patients communicated and interacted compared to non-Māori, and found they needed to adjust to be effective.

Many IMGs attempted to learn some phrases in te reo Māori and although they felt awkward about their pronunciation, their efforts were appreciated by Māori patients.

IMGs experienced a lack of support or interest in their code-switching dilemma from New Zealand counterparts, with most commenting on a sense of isolation and a lack of social support that meant IMGS usually ended up socialising together where possible.

Although IMGs expect to and are willing to adapt to the New Zealand setting, a lack of cultural orientation and support leads to frustration and can result in resentment at either not being valued for their experience or not being accepted for themselves.

Co-author and PhD supervisor Professor Tim Wilkinson, Acting Dean of Otago Medical School, says the findings reaffirm the importance of incorporating a patient’s preferences and perspectives in deciding options, and these are influenced by culture.

“Medical systems also differ considerably across countries related to disease patterns, treatment options and how health services are organised.

“The relationships within health care teams are often less hierarchical than in other countries.  Adjusting to all these differences requires effective transition arrangements which often must be targeted to the doctor’s background.”

Dr Mannes recommends implementing a cultural mentoring programme – both at orientation and in ongoing curricula – to enhance cultural wellbeing and improve practice with the aim of increasing IMG retention in New Zealand.

“Although IMGs come from comparable and incomparable health systems, they are all culturally diverse relative to New Zealand.

“Understanding cultural differences and their impact on IMGs is crucial for implementing support programmes that will help them fit in without losing themselves.”

With this support, she believes the cultural journey for IMGs may prove more manageable, encouraging them to remain, and strengthening the New Zealand population’s access to quality healthcare.

Publication details:

Cross-cultural code-switching – the impact on international medical graduates in New Zealand

Authors: Mariska M. Mannes, Davinia J. Thornley & Tim J. Wilkinson

BMC Medical Education

DOI: 10.1186/s12909-023-04900-2

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