CSIRO PUBLISHING
Australian Journal of Primary Health, 2012, 18, 197–203 http://dx.doi.org/10.1071/PY11030
Research
Grunt language versus accent: the perceived communication barriers between international medical graduates and patients in Central Wheatbelt catchments Jessica Sommer A, William Macdonald A, Caroline Bulsara A,B,D and David Lim C A
School of Primary, Aboriginal and Rural Health Care, The University of Western Australia, M706, 35 Stirling Highway, Crawley, WA 6009, Australia. B Brightwater Care Group, PO Box 762, Osborne Park, WA 6916, Australia. C Wheatbelt GP Network, 15 Elizabeth Place, Northam, WA 6401, Australia. D Corresponding author. Email:
[email protected]
Abstract. Due to the chronic shortages of GPs in Australian rural and remote regions, considerable numbers of international medical graduates (IMG) have been recruited. IMG experience many difficulties when relocating to Australia with one of the most significant being effective GP patient communication. Given that this is essential for effective consultation it can have a substantial impact on health care. A purposive sample of seven practising GPs (five IMG, two Australian-trained doctors (ATD)) was interviewed using a semistructured face-to-face interviewing technique. GPs from Nigeria, Egypt, United Kingdom, India, Singapore and Australia participated. Interviews were transcribed and then coded. The authors used qualitative thematic analysis of interview transcripts to identify common themes. IMG patient communication barriers were considered significant in the Wheatbelt region as identified by both IMG and ATD. ATD indicated they were aware of IMG patient communication issues resulting in subsequent consults with patients to explain results and diagnoses. Significantly, a lack of communication between ATD and IMG also emerged, creating a further barrier to effective communication. Analysis of the data generated several important findings that rural GP networks should consider when integrating new IMG into the community. Addressing the challenges related to cross-cultural differences should be a priority, in order to enable effective communication. More open communication between ATD and IMG about GP patient communication barriers and education programs around GP patient communication would help both GP and patient satisfaction. Additional keywords: Australian-trained doctor, rural. Received 8 March 2011, accepted 4 August 2011, published online 21 November 2011
Introduction Most medical specialties in Australia, including general practice, are experiencing workforce shortages (Brooks et al. 2003). This shortage is even more acute in rural and remote areas (Productivity Commission 2005; Department of Health and Ageing 2008). The Wheatbelt GP Network covers ~85 000 km2 in the Central Wheatbelt region of Western Australia (Wheatbelt GP Network 2010) and is one of the most under resourced areas in Australia in regard to health services (Primary Health Care Research and Information Service 2010). Ideally, the GP : patient ratio should be 1 : 1000 but in the Wheatbelt GP Network it is 1 : 1700 (Primary Health Care Research and Information Service 2011). As Australian rural communities are unable to recruit sufficient numbers of Australian-trained doctors (ATD) to take up rural practice, the recruitment of international medical graduates (IMG) to fill these shortages now forms a fundamental part of the Australian medical workforce Journal compilation La Trobe University 2012
(Alexander and Fraser 2005). One-third of doctors currently working in Australia are IMG (Department of Health and Ageing 2008) and in regional, rural and remote areas nationally, 41% of all doctors are IMG (Productivity Commission 2005; Department of Health and Ageing 2008). In the Wheatbelt GP Network ~50% of the general practice workforce comprises IMG (Australian General Practice Network 2009). Good GP patient communication is the cornerstone of effective consultation and successful health care outcomes (Rosenberg et al. 1997; Williams et al. 1998; Swenson et al. 2004; Murtagh 2008). Furthermore, it improves patient autonomy, promotes better exchange of information and plays a vital role in engaging with patients and establishing trust (Saxton and Finkelstein 2003; Duncan and Gilbey 2007). Many IMG, particularly from parts of Africa, Asia and the Middle East, have not had access to optimal communication strategies as part of their medical training (Bruijnzeels www.publish.csiro.au/journals/py
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and Visser 2005; Dorgan et al. 2009). In addition, despite communication teaching being part of the curriculum for IMG GP registrars in Australia, some IMG do not see the relevance of non-clinical training sessions (Duncan and Gilbey 2007). Interestingly, research suggests that the most common challenges experienced by IMG relocating to Australia relate to language and communication (McGrath 2004; McDonnell and Usherwood 2008). Evidence suggests a relative mismatch between the language of IMG and that of rural Australians (Duncan and Gilbey 2007), whereby most problems arise when it comes to informal language, specifically dialect, accent, speed and use of jargon (Fiscella et al. 1997; Duncan and Gilbey 2007; McDonnell and Usherwood 2008; Dorgan et al. 2009). On the other hand, when IMG converse with and advise their patients, it is in formal English, often spoken with an accent, which raises concern that the medical message may not be understood by patients clearly enough (Duncan and Gilbey 2007; McDonnell and Usherwood 2008). Even IMG with extensive English training may have difficulty detecting and understanding patients’ more subtle or informal forms of communication (Fiscella and Frankel 2000; McDonnell and Usherwood 2008). Non-verbal cues such as body language, tone of voice and expressions can be indicators of deeper issues (Mehrabian and Ksionzky 1971; Pease 1985; McDonnell and Usherwood 2008). As a result IMG may misinterpret the initial illness presentation as something less serious and fail to look beyond the presenting problem. Most Australian IMG come from non-English speaking backgrounds and as a result are faced with a series of transcultural challenges including language, gender issues, values and beliefs, lifestyle, discrimination and changes in status (Fiscella et al. 1997; Birrell 2004). These unfamiliar cultural norms and expectations can lead to problems with communication, rapport and empathy, and are often a more common source of problematic communication with patients than the unfamiliar language (Fiscella et al. 1997; McDonnell and Usherwood 2008; Dorgan et al. 2009). Furthermore, some male IMG feel untrained in taking sexual histories or performing genital examinations on female patients (Fiscella et al. 1997). This is a complex issue, not only because these doctors may be inexperienced in women’s health, but also due to cultural and personal barriers associated with physical touching and questions about sexuality across gender (Fiscella et al. 1997). It is a particular issue in Wheatbelt communities where sexual and reproductive health, particularly among young women, is a major issue (MMT Consultancy Services 2009). Racism, rapport building and acceptance by patients and the community can also be issues (McDonnell and Usherwood 2008), as not only is the GP a new addition to the small rural community, but they are also from a culturally different and unfamiliar background (Fiscella and Frankel 2000). This study explored the perceptions of the IMG regarding the barriers to effective patient communication. A comparison between ATD and IMG to identify rural and IMG-specific themes was conducted during the analysis phase.
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Methods A phenomenological framework was utilised for this study. Phenomenology is defined by Morse and Field (1995) as seeking to gain what is the essence and core meaning of participants’ experiences. A purposive sample of GPs (IMG and ATD) was interviewed to identify GP-perceived communication barriers using an in-depth interviewing technique in order to best identify the complexity of issues amongst informants. It was decided to conduct a purposive sampling technique (Patton 1990) whereby participants were deliberately selected in order to obtain a series of ‘information rich’ interviews. A total of five IMG and two ATD across five Wheatbelt towns in Western Australia were interviewed. All were selected for their experience as an IMG or an ATD in order to explore their experiences with the local community in terms of communication. Ethics for the study was granted from the Human Research Ethics Committee, University of Western Australia. Study population The study population included IMG and ATD in the Wheatbelt region of Western Australia. Purposive sampling was used to maximise data from the GP interviews (Sarantakos 1993). Two large towns in the region and three smaller towns in the surrounding areas were included in the study to ensure a realistic representation of the Wheatbelt area. An open letter of invitation to participate in the study along with a project information sheet was sent by email to all 22 GPs (12 ATD and 10 IMG) in 10 practices across eight towns in the Wheatbelt region. On receipt of the consent form and details of potential GP participants, the research team contacted the GP participant to determine their willingness to participate. If willing, a suitable interview date and time was organised at the respective medical practice. Data collection Data was collected from IMG and ATD through semi-structured, single face-to-face interviews with consenting GP participants. Each interview lasted approximately 30 min. The interview was held at the respective GP participant’s consulting room at a time and date convenient to the GP participant. Written consent was received from each GP participant before commencement of the interview and GP participants were assured they could withdraw from the study at any time without penalty and that confidentiality would be maintained. The interviews were audiotaped after further informed consent was obtained from the GP participant. Data analysis The analysis was performed manually by the researchers. Content analysis guided the interpretation of data and qualitative content analysis was used to analyse the interview transcript thematically (Sandelowski 2000). Qualitative content analysis involved thorough reading of transcripts and coding each line in the transcript before cataloguing similar codes into themes. Results GP demographics Of the 22 GPs invited to participate in the study a total of seven GPs agreed to participate. This included five IMG and two ATD
Communication barriers among rural IMGs
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from two larger and three smaller towns in the Wheatbelt region. GP participant demographics are shown in Table 1. The interview began with general questions relating to demography and training, followed by more specific questions outlined in Table 2. Major themes identified are also listed in Table 2. Accent and Australian vernacular Accent as a barrier to effective communication emerged as a predominant theme for both IMG and ATD participants (Table 3). Each GP participant interviewed commented on the role accent played in communication. The IMG participants were aware that they had considerable accents when speaking English and that this may be difficult for patients to understand (Table 3). Although being aware that accent can create a barrier to effective GP patient communication, none of the IMG participants felt that their accent was a barrier in communicating with patients (Table 3). One IMG participant with a particularly strong accent felt that his accent had changed the way he communicated with patients, that is, in order to communicate effectively he repeats himself. The role of accent as a communication barrier was not limited to the GP’s accent. Some of the IMG participants had difficulty understanding their patients, especially when they spoke quickly or came from Table 1. GP demographics Origin = country of origin, Training = country of training, Total practice = practice years in practice, Australian practice = practice years in Australia, Wheatbelt practice = practice years in Wheatbelt GP
Sex
GP1 GP2 GP3 GP4 GP5 GP6 GP7
Male Female Male Male Female Male Female
Origin
Training
UK UK Australia Australia Singapore Singapore Nigeria Nigeria India India Egypt Egypt Australia Australia
Total practice
Australian practice
Wheatbelt practice
39 24 19 19 18 11 15
25 20 12 2 7 2 15
4 7 8 2 3 2 10
interstate. Australian vernacular or slang emerged as a further challenge for IMG participants, particularly initially. One IMG participant explained that once you understood the ‘grunt language’ of Australian farmers communication improved, and another used a dictionary of Australian slang to improve his understanding. The ATD participants, and some IMG participants, were aware of the communication barriers faced by some IMG and their patients. Both ATD participants and two IMG participants had seen a patient who had made an appointment to see them following a consultation with an IMG, because the patient could not understand the IMG’s accent and use of the English language. The ATD participants emphasised that when patients came to them subsequently, it was due to the patients’ lack of understanding of the explanation or diagnosis, and not because of perceived poor treatment or any overt racism. In addition, the explanation received by the GPs from patients who deliberately do not see an IMG was that this occurs due to language barriers rather than discrimination. Despite many of the GP participants having performed consultations for patients to clarify a misunderstood diagnosis from an IMG, the IMG participants did not feel that they themselves had any communication barriers with their patients. One ATD participant commented that there are doctors that she still doesn’t understand even though they are speaking medically. Cultural Cultural differences in communication techniques can markedly impact on GP patient relationships. Some GP participants commented that the feedback they had received from patients included the need for doctors to be both good communicators and culturally sensitive, as well as less autocratic and ‘a little more human’. Due to their cultural or religious background, some male Table 3. Quotations from Australian-trained doctors (ATD) and international medical graduates (IMG) regardings accent and vernacular WA, Western Australia IMG
Table 2. Topics explored during and major themes identified from interviews ATD, Australian-trained doctor; IMG, international medical graduate; WA, Western Australia
IMG
Specific topics explored in interview
Major themes identified
IMG
Challenges relating to relocating to rural WA Challenges relating to practicing medicine in rural WA The presence of communication barriers between IMGs or ATD and patients. Are communication barriers perceived by ATD different to those of IMG? Personal experience or colleagues experience of any communication barriers
Patient difficulties with IMG accent IMG difficulties with local vernacular of patients Cultural barriers regarding women’s health
IMG
ATD
ATD Lack of communication/feedback between IMG and ATD
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ATD
‘People still have problems with my accent. . .But I don’t feel that that is a barrier. They still understand what I’m trying to say and I still understand what they are trying to say.’ ‘. . .it [accent] never really got in the way. Rather what it has done to me it has made me more of a repetitive type of person.’ ‘But regarding my accent no, no one complained about this. Fortunately no patients, no other doctors, even receptionist.’ ‘Farmers are traditionally fairly conservative crowd but once you know the grunt language you can communicate with them alright.’ ‘We are starting to get a lot of people that are coming across from [town] to see us here because the doctors in [town] the language barrier, the understanding. Sometimes they will get enough of an explanation but they don’t understand it, or they don’t get enough of an explanation. So they don’t actually complain about the treatment or what has been done, but it’s the explanation.’ ‘I think the patient’s explanation coming to me is, it’s a language issue, it’s not that they’re foreign or coloured or. . .nobody has overtly said that.’ ‘And there are doctors here that I cannot understand even though you’re speaking medical stuff, I still can’t understand.’
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IMG found it challenging when consulting female patients for women’s health issues. This resulted in patients travelling substantial distances to see an appropriate GP. Both ATD participants and IMG participants found they were seeing more female patients because either an IMG from another town, or within the same practice, was uncomfortable with women’s health (Table 4). There also appeared to be a lack of communication between IMG and ATD within the same practice. One IMG participant acknowledged he initially had difficulties with women’s health; however, he now felt comfortable with obstetrics and women’s health. Despite this, another ATD GP highlighted that they still consult female patients from certain IMG within the practice. Suggested ways forward All GP participants were asked what the Wheatbelt GP Network could do to improve communication and other issues faced by GPs. Their comments ranged from those who believed that communication between GPs needed to be improved and providing an appropriate situation in which this can be done, to those who suggested more educational workshops and financial support for medical conferences and courses (Table 5). One GP participant spoke of a previously successful program implemented by the Wheatbelt GP Network, which had a positive effect on the GPs involved. Balint Groups were specified as ‘peer support groups of GPs’ that included the mentoring of new GPs by Table 4. Quotations from Australian-trained doctors (ATD) and international medical graduates (IMG) regarding cultural barriers to communication IMG
ATD
ATD
‘I started to read and gain good experience in obstetrics and gynaecology as well and I started to see more patients and I did a couple of courses.’ ‘Whether that is a chaperone issue or a ‘nah I don’t do women below the waist issue’ but my perception is you’re a doctor, you’re trained, you should do all of that stuff, but maybe they have a different perspective on it.’ That is one thing that I have definitely noticed, that I get a lot more of that kind of work, because a certain group of overseas-trained doctors won’t do that work.’
Table 5. Quotations from Australian-trained doctors (ATD) and international medical graduates (IMG) suggesting ways forward IMG
ATD
ATD
ATD
‘This would be a good experience. But honestly I don’t have an idea about how we can do that. We are very busy here. And if I’m busy I would have to decline from something like this.’ ‘They [Balint Groups], I think, are very helpful for IMG as they can bring up issues about what is ok and what is not ok in this culture. It is very difficult to teach that sort of stuff other than in a group setting like that . . . A group of doctors talking is a powerful thing.’ ‘If for example you’re consistently getting patients from a particular doctor with a problem, then if you know that GP then you may have some better way of feeding that information back to them.’ ‘Having simple things like having a printed report of the result rather than just verbal and then maybe going through the report together.’
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older GPs. When other GP participants were asked if they would be interested in such programs, the response was largely positive. However, the GP participants commented on the difficulty of implementing such a program, in particular the logistics of getting a group of very busy doctors together when they live in different towns sometimes hundreds of kilometres apart. One ATD participant highlighted the need for more social and professional functions to facilitate networking between doctors in both an educational and social scenario. They pointed out that networking was important as it provided feedback to other GPs, particularly IMG, in an appropriate and sensitive way. Furthermore, they felt it was a particularly useful way for IMG to become aware of problems their patients might have with them, for example a doctor may not be aware that patients are not seeing them because the patients can’t understand them. Overcoming this may simply involve the introduction of effective ways of communicating information to patients, increasing patient awareness and encouraging patients to be more proactive. The ATD participant also discussed the issue of supervision for some IMG so that any problems can be identified before they become much bigger problems. Discussion Our study sought the views of IMG and ATD toward GP patient communication barriers in the Central Wheatbelt region of Western Australia. The major communication barriers identified by GP participants were: accents of IMG and their use of English; the regional vernacular used by Wheatbelt patients, referred to as the ‘grunt language’; and cultural differences, particularly relating to women’s health. This lead to situations of miscommunication and inadequate IMG patient communication and resulted in the need for subsequent consults, for the same clinical presentation, in order to clarify diagnosis and explanation. This miscommunication creates potential inefficiency within general practice, which is exacerbated by the lack of communication between GPs within the practice and more widely across the catchment area. IMG did not feel that they had communication barriers with patients One important finding from this study was that although IMG participants acknowledged that accent and language could create a barrier to effective communication with patients, the IMG participants did not perceive that their accent and English language skills served as a barrier to their interactions with patients (Table 3). This is a similar finding to Dorgan et al. (2009). Although some IMG participants recalled that language was a major hurdle when they first arrived in Australia, they now felt that their communication and language skills toward patients were satisfactory, which is consistent with the literature (McDonnell and Usherwood 2008). This was interesting as the ATD participants and two IMG participants reported that communication barriers do exist with IMG (discussed below). Formal English is not a communication barrier for most IMG as they have had extensive formal training in the English language (McDonnell and Usherwood 2008). This was true for our IMG participants; however, it was the regional vernacular or ‘grunt
Communication barriers among rural IMGs
language’ of Wheatbelt farmers that was perceived as a real communication barrier. Therefore, IMG participants acknowledged having difficulties understanding patients at times but did not perceive that their patients may be having difficulties understanding them. It could be the case that the IMG participants in this study are truly not those with communication barriers, or they are not aware that their patients have problems with understanding the consultation. Poor communication, including that between GPs, creates inefficiency within general practice ATD participants explained how the difficulty in understanding some IMG created a significant barrier to communication. The extent of this problem was highlighted in that all of the ATD participants and two IMG participants had seen patients who had made a subsequent appointment with them, after an initial consult with an IMG. Subsequent GPs noted that patients reported being unable to understand the IMG during the initial consultation. The initial IMG may not be aware of the request to see a subsequent GP, thus some IMG may need assistance in understanding the barriers associated with their accent and English speaking skills. A better understanding of how accent and instances of suboptimal use of English can affect patients may also allow IMG to identify difficulties in patient communication. For example, patients sometimes say they understand what has been conveyed during the consult even if this is not the case. This issue emphasises the inefficiency that poor GP patient communication creates in having to see two different doctors for one diagnosis. Three GP participants noted an increasing number of consults relating to women’s health. Some male IMG feel uncomfortable and untrained in taking sexual histories or performing genital examinations on female patients because few women in their country of training consider it appropriate to see a male doctor (Saha et al. 2008). One IMG participant acknowledged that he initially had difficulties with women’s health; however, he felt that he was now quite comfortable with this area of general practice. However, ATD participants from the same practice explained that they still consult female patients from certain IMG due to patient doctor communication difficulties. This highlights the lack of communication between GPs themselves, and indicates the need for a sensitive and standardised feedback mechanism to be put in place to assist IMG with a problem identified by other GPs. The demand for patients to see two doctors for the same presenting complaint, or travelling distances to see a subsequent doctor, is a significant problem. Not only does this increase travel time for patients, affect patient accessibility to care and increase costs for the patient, it also places more pressure on those GPs who find they are servicing a larger patient population. This also raises the question as to how many patients who have difficulties understanding a consult actually book a subsequent appointment, given the difficulties in obtaining and accessing appointments and the initial reluctance to seek medical care (Malcher 2009). In addition, general practice in these cases becomes highly inefficient, in an area where the doctor shortage is already severe (Primary Health Care Research and Information Service 2010).
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This issue again highlights suboptimal communication between ATD and IMG within the same network. Suggestions for improvement Many GP participants noted that interaction with other GPs, both in a professional and social context, was limited, perhaps contributing to the general lack of feedback processes available to IMG (McGrath 2004). One ATD participant suggested that there is a need for more social and professional functions to facilitate networking between doctors. This creates a means for providing feedback to other GPs, particularly IMG, in an appropriate and sensitive way. As suggested by some GP participants, Balint groups may be useful in this regard, as they are small educational groups where GPs discuss cases with an emphasis on the doctor patient relationship. They have previously been shown to increase the ability of GPs to cope with difficult GP patient interactions and psychologically challenging situations as well as increase professional satisfaction (Lustig 2006). It was suggested by ATD participants that for the communication barriers relating to accent and language, all it may take to improve communication is providing the patients with a physical copy of their results or a written explanation. The GP and patient could then revise the printed information together during the consult. Decision aids, such as written explanations, have been show to be beneficial for GP patient communication and patient satisfaction (Epstein et al. 2004; Thistlethwaite et al. 2006). This would be particularly useful for hearing-impaired patients. Other processes that may help optimise GP patient communication include formal supervision of IMG, by more experienced GPs, from the time of their appointment in a rural practice and formal assessment of IMG interpersonal skills during consultation using a doctor’s interpersonal skills questionnaire. A doctor’s interpersonal skills questionnaire is a process where patients survey a doctor’s communication skills with anonymous feedback that is professionally relayed to the IMG along with strategies for improvement. The ATD participants commented on the importance of community involvement, particularly in order to become accepted into the community. This may provide additional benefits to IMG in particular. Spending time (outside the medical office) interacting in the local vernacular, rather than returning home to a spouse or family members who prefer to speak in their primary language, may assist IMG understand the barriers related to their English speaking skills. Activities encouraging IMG to interact in the local vernacular may be useful in addressing some of these multilayered communication barriers. IMG who are aware that their patients have trouble with their accent or language may be able to detect when patients do not understand. This would then allow the miscommunication to be addressed at the time of the consult. Although research suggests that some IMG experience racism in Australia (Sweet 2006; Arkles et al. 2007; McDonnell and Usherwood 2008), there was no mention of racism from our GP participants. Findings showed that when patients deliberately do not see an IMG, it is mostly due to language difficulties rather than discrimination (Table 3). It could of course be the case that those patients who are racist simply choose not to see an IMG, or that patients do not cite racist reasons for choosing to see an ATD
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for subsequent appointments. None of the IMG participants felt that they had been discriminated against. Furthermore, many of the GP participants perceived rural communities to be quite accepting and appreciative of new GPs entering the community and felt that the multiculturalism that this provides in Wheatbelt communities is positive. A recent Australian study described a high level of patient satisfaction and acceptance of receiving care from IMG (Harding et al. 2010). This reinforces the perception that IMG are valued members of the medical profession in Australia. The question remains regarding the anomaly between IMG believing themselves to be well understood by patients and patients stating that there was a lack of understanding (language) in relation to the IMG. It is difficult to understand why the problem is still occurring. Either IMG are not aware that the problem exists or they feel that it is not a problem. These are major communication issues, which should be explored in further research.
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communication between ATD and IMG. The outcomes of this study can help direct future investigations about the real and perceived IMG patient communication barriers. Furthermore, this study offers IMG, ATD and patient perspectives and experiences, thereby encouraging and providing a foundation for discussion among medical practitioners, rural health networks, IMG trainers and patients in an attempt to improve the communication between IMG and their patients. Conflicts of interest None declared. Acknowledgements The authors would like to thank Paul West and the staff at the Wheatbelt GP Network for their advice before and during the project. In addition, we thank the Primary Health Care Research Evaluation and Development unit of General Practice at the University of Western Australia for funding through a PHCRED scholarship awarded to W. M. and J. S.
Study limitations and implications for further research The findings presented in this study must be placed in the context of several important limitations. First, the IMG participants rarely reported barriers to communication with patients to the researchers. From the perspective of the ATD participants, it emerged that there are apparent barriers. The small sample size of two ATD is not sufficient to estimate the size of the problem. Yet informal observations of IMG participants and discussions with patients, practice staff and Wheatbelt GP Network staff suggest that there may indeed be a more significant problem than was captured in this study. The IMG participants may not be aware of the request made by patients to change to a different doctor; however, this could not be adequately explored in this study. It is therefore our recommendation to further investigate the miscommunication between IMG and patients, and between IMG and ATD. Second, the IMG participants did not report any challenges in adjusting to Australian cultural norms, the use of non-verbal communication cross culturally, or integration into a new and foreign community. This was surprising, as evidence to the contrary continues to be reported in the literature (McDonnell and Usherwood 2008). The IMG participants reported very few challenges at all, which may have been a function of the interview process. In a future study the use of more targeted questions, as well as an anonymous written account, may be valuable in extracting such information. It is also suggested that as the researchers are students, this may have had an effect on the depth of private information the IMG participants wished to disclose. Due to the qualitative nature of this study, there is no intent to extrapolate the findings to other IMG or patient populations. We explored GP perceptions of communication barriers, and as such we also did not intend to identify the reality of all IMG communication barriers with their Wheatbelt patients. Conclusion It was striking to note that communication issues were salient, despite IMG participants perceiving that their accent and English language skills did not serve as a barrier to their interaction with patients. It was also recognised that there are significant gaps in
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