Background
International Medical Graduates (IMGs) are known to perform less well in many postgraduate medical examinations when compared to their UK trained counterparts. This “differential attainment” is observed in both knowledge-based and clinical skills assessments. This study explored the influence of culture and language on IMGs clinical communication skills, in particular, their ability to seek, detect and acknowledge patients’ concerns in a high stakes postgraduate clinical skills examination. Hofstede’s cultural dimensions framework was used to look at the impact of culture on examination performance.

Methods
This was a qualitative, interpretative study using thematic content analysis of video-recorded doctor-simulated patient consultations of candidates sitting the MRCP(UK) PACES examination, at a single examination centre in November 2012. The research utilised Hofstede’s cultural dimension theory, a framework for comparing cultural factors amongst different nations, to help understand the reasons for failure.

Results
Five key themes accounted for the majority of communication failures in station 2, “history taking” and station 4, “communication skills and ethics” of the MRCP(UK) PACES examination. Two themes, the ability to detect clues and the ability to address concerns, related directly to the overall construct managing patients’ concerns. Three other themes were found to impact the whole consultation. These were building relationships, providing structure and explanation and planning.

Conclusion
Hofstede’s cultural dimensions may help to contextualise some of these observations. In some cultures doctor and patient roles are relatively inflexible: the doctor may convey less information to the patient (higher power distance societies) and give less attention to building rapport (high uncertainty avoidance societies.) This may explain why cues and concerns presented by patients were overlooked in this setting. Understanding cultural differences through Hofstede’s cultural dimensions theory can inform the preparation of candidates for high stakes bedside clinical skills examinations and for professional practice.