Table 3.

Noted problems/difficulties in academic contact situations

Theme	Quotations
Linguistic/communicative aspect
Listening	I could express what I wanted to during one-to–one interactions with clinical teachers, but, it was difficult to follow conversations between doctors in the ward and ICU rounds. In fact, I could grasp only around 30–40% of these conversations. I was shocked at how little I understood in the first few days. (Student 34)
Speaking and expression of opinion	[Expression of the detailed nuances] When the doctor questioned me about things like, ‘What do you want to do today?’ expecting my self-directed attitude, I could only respond with, ‘I want to observe surgery.’ I wanted to express more but I could not do so. I was very frustrated with my English. (Student 34)
	[Self-expression] I could not answer questions of the medical staff about clinical issues properly and coherently because I could not fully express everything I had in mind in English. This upset me and I sometimes made me doubtful about my ability to spend time productively in the US. (Student 41)
	[Presentation/explanation] I was so nervous that my voice and hands trembled when I conducted my first medical interview with a patient. My mind went blank and I was at a loss for words. When I was reporting on the patient condition to the doctor, his facial expressions made his discomfort with my English obvious. (Student 6)
Vocabulary/abbreviation	There were a high number of abbreviations compared to Japan. As there were often drugs with different brand-names on patient notes, I was confused and had difficulty in comprehending the information. (Student 23)
Sociolinguistic aspect
Self-positioning	… as a student there, I did not know how actively I could ask for the opportunity to observe a surgery and how I could be involved in the surgery. (Student10)
Relationship with supervisor and other medical staff	My supervisor was very busy with his duties, and I did not know when I could ask him a question. When I did, he spoke too quickly for me to grasp his answer. … I had no idea about how to behave appropriately in this situation in a different cultural context. (Student 13)
Communication with patient	I think that my problem was that I could not conduct medical interviews well by taking the patient’s social and psychological backgrounds into account. (Student 35)
Sociocultural aspect
Different educational culture from their home country	[Student autonomous learning culture] The doctor did not assign tasks to me. Instead, I had to tell him what I wanted to do. As I was unaware of this educational culture, I could not do anything in the first few days. (Student 3)
	[Student responsibility] On the first day, I wanted to observe the doctor during ward rounds, but I was asked abruptly to make a patient note. It was not a SOAP format, and I became nervous because I had no idea about how and what to write on the form. Realising my struggle, a fellow doctor took the patient note from me and said, ‘I can do it.’ I was annoyed by my own uselessness and felt alienated. (Student 17)
	[Different educational systems] The students in North America enrolled in medical school after graduating from college and had already participated in many rotation programs. The responsibilities of local medical students were possibly equivalent to ones of junior residents in Japan … Although we’re all ‘medical students,’ they were much more knowledgeable and had more clinical experience. Consequently, I developed an inferiority complex and lost my self-confidence. (Student 15)
	[‘Competitive’ culture] In the second week onward, some local medical students joined our team … One day, the doctor asked us about the characteristic findings of Crohn’s disease. A student next to me answered immediately while I was still processing the question. It was highly competitive, and I had to invest more efforts into not just improving my English but also my medical knowledge. (Student 36)
Clinical ethics	I was given a chance to be in charge of a patient whose testicular cancer had metastasised to his entire system. Australia had more patients who were informed about their cancer diagnosis compared to Japan. So, at first, I was really worried about how to communicate with a cancer patient in such a situation. (Student 14)