CROSSING BORDERS: A GROUNDED THEORY STUDY ON INTERNATIONAL MEDICAL STUDENTS IN THE UNITED STATES by Tolulope Joaquim December, 2025 Director of Dissertation: Andrew Brimhall, PhD Major Department: Human Development and Family Science ABSTRACT The number of international students enrolled in medical schools worldwide continues to rise. In response to the growing shortage of healthcare personnel, many countries are expanding enrollment in health-related disciplines to meet national healthcare demands. This expansion has led to an increasing influx of international students into medical programs, including those in the United States. While International Medical Students (IMSs) share many challenges faced by domestic students, they also encounter unique cultural, financial, and psychosocial stressors. This dissertation examines these challenges and the support systems IMSs utilize across five chapters. Chapter 1 introduces and reviews existing literature on IMSs, focusing on their challenges and support systems, and provides some context about studying medicine in the United States. Chapter 2 presents a systematic review of research exploring how psychosocial support systems and resources shape IMSs’ experiences in medical school. Chapter 3 outlines the methodology for an original grounded theory study. Chapter 4 presents the findings of this original grounded theory study, offering an in-depth understanding of IMSs’ experiences and practices in U.S. medical schools and generating a theoretical framework to guide the development of more responsive institutional policies and support initiatives. Finally, Chapter 5 discusses the implications of these findings for IMSs, medical schools, and healthcare providers who interact with or support these learners. Keywords: International Medical Students, acculturation, psychosocial support, medical education, student well-being CROSSING BORDERS: A GROUNDED THEORY STUDY ON INTERNATIONAL MEDICAL STUDENTS IN THE UNITED STATES A Dissertation Presented To the Faculty of the Department of Human Development and Family Science East Carolina University In Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy in Medical Family Therapy by Tolulope Joaquim December, 2025 Director of Dissertation: Andrew Brimhall, PhD Dissertation Committee Members: Angela Lamson, PhD Kayla Fitzke, PhD Matthew Drake, MD © Tolulope Joaquim, 2025 ACKNOWLEDGMENTS “It takes a village—not just to raise a child, but to raise a dream.” This African proverb captures the heart of my journey. Nothing about completing this dissertation or this doctoral program was done alone. God’s guidance, strength, and grace carried me through every challenge, breakthrough, delay, and moment of clarity. I am profoundly grateful for the ways He opened doors and surrounded me with the support I needed. I stand here because many people supported, challenged, and uplifted me, even when I struggled to believe in myself. To my dissertation committee—thank you for your guidance, patience, and commitment to my growth. To my chair, Dr. Andy Brimhall, your steady mentorship, grounding presence, and consistent encouragement strengthened my writing, sharpened my thinking, and helped me stay balanced throughout this process. I am grateful to the faculty in the ECU Medical Family Therapy PhD program as well. I am especially grateful to my dissertation committee —Dr. Angela Lamson, Dr. Kayla Fitzke, and Dr. Matthew Drake —for your expertise, intellectual challenge, and support through life’s transitions. A special thank you to Kerry Sewell, MSLS, for your help—especially at the beginning of this work—your resources and your belief in the importance of this work were invaluable. To the participants—thank you for trusting me with your stories. Your honesty, strength, and perseverance made this dissertation possible and inspired every chapter. To my family— thank you for being my foundation. To my husband, Joaquim, your love and unwavering support sustained me through long nights and long seasons. To my precious son, born in the midst of this journey, you brought joy to exhaustion and purpose to perseverance. To my parents, thank you for planting the seeds of faith, resilience, and curiosity, and for the sacrifices that allowed me to leave home at sixteen to pursue my dreams. To my siblings, your humor, pride, and steady encouragement kept me grounded. To my mom-in-love, thank you for embracing me with warmth, understanding, and prayer; your support lightened my load in the hardest moments. To my friends—thank you for checking in, lifting my spirits, and celebrating every milestone. Your presence mattered more than you know. Finally, to everyone who contributed to this accomplishment, in big or small ways, thank you. This dissertation reflects not only my work, but the collective love, wisdom, and support of an entire community. I am better—and here— because of you. TABLE OF CONTENTS TITLE PAGE .................................................................................................................................. i COPYRIGHT .................................................................................................................................. ii ACKNOWLEDGEMENTS ........................................................................................................... iii LIST OF TABLES ......................................................................................................................... xi LIST OF FIGURES ...................................................................................................................... xii PREFACE .................................................................................................................................... xiii REFERENCES ............................................................................................................... xvii CHAPTER 1: INTRODUCTION ................................................................................................... 1 The Desire to Study Abroad ............................................................................................... 2 Challenges Faced by IMSs.................................................................................................. 3 Acculturation and Social Adjustment ..................................................................... 3 Financial and Systemic Hurdles.............................................................................. 5 Support Systems and Coping Strategies ............................................................................. 5 Unique U.S. Context ........................................................................................................... 6 Rationale for This Study ..................................................................................................... 7 REFERENCES ................................................................................................................... 9 CHAPTER 2: CROSSING BORDERS: A SYSTEMATIC REVIEW OF INTERNATIONAL MEDICAL STUDENTS’ EXPERIENCES .................................................................................. 17 Method .............................................................................................................................. 19 Article Search Strategy and Selection................................................................... 19 Data Extraction and Synthesis .............................................................................. 21 Results ............................................................................................................................... 21 Key Factors Influencing IMSs’ Experiences ........................................................ 29 Acculturation............................................................................................. 23 Language and Communication ..................................................... 24 Stress, Anxiety, Depression, and Coping ...................................... 24 Discrimination and Prejudice ........................................................ 25 Economic Needs ........................................................................... 26 Social Support that Influences IMSs’ Experiences in Medical School ................ 26 Psychosocial Resources that Influence IMSs’ Experiences in Medical School .. 28 Discussion ......................................................................................................................... 29 Recommendations ................................................................................................. 32 Limitations ............................................................................................................ 34 Conclusion ........................................................................................................................ 34 REFERENCES ................................................................................................................. 36 CHAPTER 3: METHODOLOGY ................................................................................................ 56 Grounded Theory .............................................................................................................. 56 Bracketing: Researcher’s Background and Perspectives ...................................... 58 Sampling ............................................................................................................... 59 Recruitment ............................................................................................... 60 Selection Criteria ...................................................................................... 62 Measures ............................................................................................................... 62 Demographic Survey ................................................................................ 63 Interpersonal Support Evaluation List ..................................................... 63 Procedures ............................................................................................................. 64 Semi-Structured Individual Interviews ..................................................... 64 Data Analysis ........................................................................................................ 65 Data Coding .............................................................................................. 66 Trustworthiness and Credibility in Qualitative Research ..................................... 67 Participant Feedback ................................................................................. 67 Memos....................................................................................................... 68 Internal and External Auditors .................................................................. 69 Conclusion ........................................................................................................................ 69 REFERENCES ................................................................................................................. 71 CHAPTER 4: COUNTING THE COSTS: A TENTATIVE GROUNDED THEORY ON THE EXPERIENCES OF IMSs IN THE UNITED STATES .............................................................. 75 Introduction ....................................................................................................................... 75 Methodology ..................................................................................................................... 77 Bracketing: Researcher’s Background and Perspectives ..................................... 77 Sampling ............................................................................................................... 78 Procedures ............................................................................................................. 78 Data Analysis ........................................................................................................ 79 Results ............................................................................................................................... 80 Overview of the Model ........................................................................................ 81 Central Category: The Continual Balancing Act ................................................. 82 Category 1- Pre-medical School Years ................................................................. 84 Challenges ................................................................................................. 84 Delayed Education ........................................................................ 84 Feelings of Doubt .......................................................................... 85 Lack of Support............................................................................. 85 Support ...................................................................................................... 86 Desire to be a Doctor .................................................................... 86 Financial Support .......................................................................... 86 Organized Mentorship .................................................................. 87 Category 2- Pre-clinical Years .............................................................................. 88 Challenges ................................................................................................. 88 Lack of Support (Financial and Social) ........................................ 88 Feeling Like An Outsider.............................................................. 90 Increased Academic Pressure ....................................................... 91 Support ...................................................................................................... 92 Time Management ........................................................................ 92 Social Support ............................................................................... 92 Institutional Support...................................................................... 94 Category 3- Clinical Years.................................................................................... 95 Challenges ................................................................................................. 95 Lack of Program Support .............................................................. 95 Increased Pressure to Perform ...................................................... 97 Barriers to Opportunities............................................................... 98 Lack of Connections ..................................................................... 98 Support ...................................................................................................... 99 Proactive in Seeking Support ........................................................ 99 Variation Among Participants............................................................................. 100 Sasha ....................................................................................................... 100 March Doe .............................................................................................. 101 Tola ......................................................................................................... 103 Tentative Hypotheses .......................................................................................... 105 ISEL Scores ........................................................................................................ 106 Summary of results ............................................................................................. 107 Discussion ....................................................................................................................... 108 Results in Existing Literature.............................................................................. 109 Recommendations ............................................................................................... 111 Recommendations for IMSs ................................................................... 111 Starting Early .............................................................................. 111 Relying on Your Support System ............................................... 112 Focusing on What is in Your Control ......................................... 113 Recommendations for medical school programs .................................... 113 Hiring an Advisor Trained to Support IMSs............................... 113 Having Established Mentoring Programs .................................. 114 Providing Clear Financial Resources for IMSs ......................... 115 Strengths and Limitations ................................................................................... 116 REFERENCES ............................................................................................................... 119 CHAPTER 5: DISCUSSION ...................................................................................................... 127 Dissertation Review ........................................................................................................ 127 Connecting Study Findings to Medical Family Therapy .................................... 131 Implications for IMSs ......................................................................................... 132 Implications for Medical School Programs ........................................................ 134 Implications for MedFT ...................................................................................... 136 Implications for Future Research ........................................................................ 137 Conclusion ...................................................................................................................... 139 REFERENCES ............................................................................................................... 141 APPENDIX A: INSTITUTIONAL REVIEW BOARD APPROVAL ....................................... 148 APPENDIX B: RECRUITMENT EMAIL ................................................................................. 149 APPENDIX C: RECRUITMENT FLIER .................................................................................. 150 APPENDIX D: CONSENT FORM ............................................................................................ 151 APPENDIX E: DEMOGRAPHIC SURVEY ............................................................................. 155 APPENDIX F: ISEL SCALE ..................................................................................................... 160 APPENDIX G: SEMI-STRUCTURED INTERVIEW .............................................................. 164 APPENDIX H: PARTICIPANT SUMMARIES ........................................................................ 166 LIST OF TABLES CHAPTER TWO 1. Reproducible Search Terms for PubMed ........................................................................... 47 2. Included Articles Characteristics ....................................................................................... 48 3. Key Factors Influencing IMSs’ Experiences in Medical School ....................................... 52 CHAPTER FOUR 1. Demographic Characteristics of Participants ..................................................................... 124 LIST OF FIGURES CHAPTER TWO 1. PRISMA Flowchart of the Inclusion/Exclusion Process .................................................. 55 CHAPTER FOUR 1. Theoretical Model for Experiences of IMSs in the United States .................................... 126 PREFACE Over a decade ago, I moved to the United States as an international student with an F-1 visa, with the goal of becoming a medical doctor. While I initially studied biochemistry, my interests gradually shifted toward social sciences, where I felt a deeper connection to understanding human behavior and relationships. Psychology’s capacity to understand and influence human experience resonated with my strengths and passions. After earning my biochemistry degree, I changed direction and completed a master’s in Marriage and Family Therapy. This decision ultimately led me to pursue a doctoral degree in Medical Family Therapy (MedFT), marking a pivotal transition in my career (Hodgson et al., 2014). Studying MedFT has enabled me to blend my diverse interests in medicine and psychology, offering a unique perspective on the world and clinical practice. It has deepened my understanding of the biopsychosocial-spiritual (BPSS) challenges faced by individuals involved in medical education, from students to healthcare providers (Engel, 1977). Having personally experienced life as an international student and observed peers in medical training across the U.S., I strongly relate to the challenges and strengths of international medical students (IMSs). Combining my personal insights and training as a Medical Family Therapist, I aimed to understand the personal and systemic challenges faced by IMSs—such as language barriers, acculturative stress, and financial difficulties—and the support systems they depend on, since I also firmly believe in the transformative power of psychosocial support systems like peer networks, community ties, and mentoring. My goal was to provide insights that could assist IMSs, medical schools, and healthcare systems in creating more responsive policies and support initiatives. These insights, perspectives, and training motivated my research on IMSs. Purpose Although my personal experiences initially sparked my interest in understanding the experiences of IMSs in the United States, the focus of my research sharpened as I reviewed the existing literature. Much of the global scholarship explores IMSs’ experiences, yet the U.S. context remains significantly underexamined. Moreover, existing studies rely heavily on quantitative measures focused on acculturative stress, anxiety, and depression rather than capturing the depth of IMSs’ lived experiences. This gap in qualitative research, particularly in the United States, led me to examine IMSs’ experiences through a qualitative lens. Across the chapters of this dissertation, the unique experiences and support systems of IMSs studying medicine in the United States are explored in detail. Chapter 1 introduces the broader healthcare climate contributing to increased IMS enrollment worldwide and provides a literature review examining IMSs’ motivations for studying medicine abroad, the academic, social, and cultural challenges they encounter in host countries, and the ways these experiences shape their adjustment and well-being. The chapter also reviews the support systems IMSs rely on as they navigate these challenges. Chapter 2 presents a systematic review assessing how psychosocial support systems and resources influence IMSs’ experiences in medical school. This review identified 32 studies examining IMSs' experiences globally and highlighted the limited literature focusing specifically on the United States, as well as the predominance of quantitative approaches. The chapter concludes with recommendations for improving IMSs’ acculturation experiences and enhancing psychosocial support resources and initiatives that medical schools can implement. Drawing on findings from Chapters 1 and 2, Chapter 3 outlines the methodology used in the original research study presented in Chapter 4. Chapter 3 details the grounded theory methodology used to investigate the experiences of IMSs in the United States. This qualitative approach offered a systematic means of generating theory directly from participants' narratives (Charmaz, 2014). IMSs across the country were recruited and interviewed until data saturation was reached. Using the constant comparative method, the researcher engaged in iterative coding—beginning with line-by-line analysis and progressing toward the identification of patterns, relationships, and core categories. This process resulted in a preliminary theory describing the challenges IMSs face and the support resources they rely on throughout medical school. To enhance credibility and trustworthiness, the study incorporated participant feedback, analytic memoing, and both internal and external audits to ensure that findings reflected participants' perspectives rather than researcher assumptions (Foley & Timonen, 2015). Chapter 4 draws directly from the methodology established in Chapter 3 to present the dissertation’s original contribution to the field. Chapter 4 presents the grounded theory study exploring the experiences and practices of IMSs in the United States and addresses the research question: What are the experiences and practices of IMSs in the United States, and how do these inform the development of a theory to guide medical schools in creating more responsive policies and support initiatives? Based on interviews with 15 participants, the findings highlight the continual balancing act between the challenges IMSs encounter and the support systems available to them. These experiences span academic, financial, social, and cultural domains, beginning in the pre-medical years and continuing through preclinical coursework and clinical rotations. From these findings, four hypotheses emerged: (1) IMSs with less institutional, financial, or social support in the host country faced greater difficulties managing medical school demands; (2) increased challenges in the host country resulted in higher stress levels, especially when students managed these demands alone; (3) elevated stress from managing these challenges—such as having less institutional, financial, or social support—hindered their professional growth and sense of success; and (4) limited early support in the initial stages of medical school (pre-med and pre- clinical years) led to compounded challenges during clinical rotations and residency. The chapter concludes by situating these findings within the broader literature and offering theoretical and practical recommendations for IMSs and the programs that train them. Chapter 5 synthesizes the contributions of the systematic review (Chapter 2) and the grounded theory study (Chapter 4). It also presents implications for IMSs, medical schools, healthcare providers, future researchers, and the field of Medical Family Therapy, emphasizing the importance of developing comprehensive support systems for IMSs. Conclusion This dissertation examines the experiences, challenges, and support systems of IMSs in the United States. Its aim is to raise awareness of the distinct needs of IMSs from their pre- medical years through their clinical training and to encourage the development of support structures and initiatives that more effectively serve them. By investing in the well-being of IMSs, medical schools not only enhance student success but also contribute to addressing the growing physician shortage in the United States and worldwide. REFERENCES Charmaz, K. (2014). Constructing grounded theory (2nd ed.). Sage. Engel, G. L. (1977). The need for a new medical model: a challenge for biomedicine. Science, 196(4286), 129-136. Foley, G., & Timonen, V. (2015). Using grounded theory method to capture and analyze health care experiences. Health Services Research, 50(4), 1195- 1210. https://doi.org/10.1111/1475-6773.12275 Hodgson, J., Lamson, A., Mendenhall, T., & Crane, D. R. (2014). In Hodgson J., Lamson A., Mendenhall T. and Crane D. R.(Eds.), Medical family therapy: Advanced applications (1;2014; ed.). Springer. https://doi.org/10.1007/978-3-319-03482-9 https://doi.org/10.1007/978-3-319-03482-9 CHAPTER 1: INTRODUCTION The Association of American Medical Colleges (AAMC, 2023) forecasts a shortage of up to 124,000 physicians in the United States by 2034. This shortfall is attributed to an aging physician population and a substantial number of current physicians retiring. Meanwhile, the World Health Organization (WHO) predicts a global lack of 10 million healthcare workers during the same timeframe, with low- and middle-income countries facing the largest decline (WHO, 2023). To address the rapid decline in healthcare personnel, medical institutions around the globe are seeking to increase enrollment in healthcare disciplines to mitigate these reductions and meet their nations' healthcare needs (American Association of Colleges of Nursing, 2024; Rizwan et al., 2018). Efforts to raise enrollment have led many countries to welcome a growing population of international students in healthcare disciplines. Nations such as the United States, China, Australia, New Zealand, Germany, and more are known for hosting international students pursuing medical education and training (AAMC, 2023; Huhn et al., 2015; Lu et al., 2022; McGrail et al., 2019). According to the Organization for Economic Cooperation and Development (OECD, 2022), international students make up one in five individuals enrolled in higher education research programs, including medical schools. Specifically, in the United States, statistics indicate an annual rise of up to 15% in the number of international students within higher education research programs since 2000, leading to over 1 million international students in the U.S. (Institute of International Education Network, 2023). More specifically, although IMSs constitute only about 1% of all medical school applicants in the United States, the increasing influx of international students in the United States may suggest a potential rise in IMS matriculants (Virji, 2021). 2 While some research exists regarding the experiences of IMSs, more literature focuses on International Medical Graduates (IMGs), especially within the United States since IMGs in the United States make up a substantial amount of its physician workforce (American Medical Association, n.d.). IMGs are medical graduates/doctors who have completed their primary medical qualification in a different country and joined the workforce of a host country to practice medicine (Al-Haddad, 2024). IMGs constitute about a quarter of all physicians in the U.S. and are vital to the American healthcare system, particularly in treating underserved populations (American Medical Association, n.d.; Asaad et al., 2025; David & Issaka, 2021). A systematic review of the intercultural challenges faced by IMGs showed that they must adjust to a new medical system with its unique care approaches, manage language nuances in the host country (such as colloquialisms), and resolve immigration issues/unique hiring processes (Michalski et al., 2017). Another study highlighted that IMGs face discriminatory and biased attitudes from both patients and colleagues (Pemberton et al., 2022), often caring for the most socioeconomically disadvantaged and minority populations that local graduates hesitate to work with (Schut, 2022). Therefore, although IMGs and IMSs share some similarities, this dissertation focuses on IMSs studying medicine worldwide, with particular attention to IMSs in the United States. The Desire to Study Abroad For IMSs, choosing to study medicine abroad often reflects a deliberate pursuit of high- quality educational opportunities and environments that promote personal and professional growth (Huhn et al., 2016). Many students look for institutions that appreciate their hard work and abilities, and they seek institutions that offer rigorous academic programs and diverse experiences that promote independence and resilience (Huhn et al., 2016; Sisavath, 2021). 3 Studying abroad also enhances employability by helping students develop interpersonal, communication, and cross-cultural competencies (Sisavath, 2021). Through engagement with peers, faculty, and patients in the host country, IMSs cultivate intercultural awareness, preparing them for a globalized workforce (Bennett et al., 2013). The benefits of enrolling IMSs extend to U.S. institutions as well. International students contribute to the workforce talent pool, generate significant tuition revenue, and enrich the cultural and educational environment for domestic students (Bennett et al., 2013; Bound et al., 2021; Olivas & Li, 2006). Furthermore, IMSs help address physician shortages in underserved areas during residency and post-graduation (Datta & Miller, 2012; McElvaney & McMahon, 2024). Although there are strong motivators and benefits to pursuing medicine in a different country, this pursuit is not without its challenges. These challenges will be discussed in the following section. Challenges Faced by IMSs Despite their contributions, IMSs face multifaceted challenges affecting personal, social, and systemic aspects of their academic and professional lives (Oduwaye et al., 2023). These challenges include personal hurdles such as language barriers, communication difficulties, and mental health concerns like stress and anxiety due to the process of acculturation (Aziz et al., 2020; Picton et al., 2022). Systemic hurdles include financial pressures, immigration constraints, and limited institutional support (Datta & Miller, 2012; Mori, 2000). Acculturation and Social Adjustment Acculturation plays a critical role in shaping the experiences of IMSs, influencing how they adapt to new environments and challenges (Smith & Khawaja, 2011). These students are often faced with the complex task of integrating into a new cultural and educational setting while 4 simultaneously striving to maintain aspects of their original cultural identity, which can serve as a source of comfort and stability during their transition (Schwartz & Zamboanga, 2008). The degree of acculturative stress experienced can vary widely among students, depending on several factors such as language proficiency, the cultural distance between their home country and the host country, and the availability of support systems like counseling, peer networks, and academic resources (Kristiana et al., 2022; Lazarus & Folkman, 1984). Some IMSs encounter heightened levels of anxiety, depression, or social isolation during this process, which can adversely affect their academic performance and overall well-being during this adjustment period (Acharya & Sahani, 2022; Chen & Sun, 2024; Shah et al., 2021). Furthermore, being separated from their families, amid cultural unfamiliarity and the lack of established social support systems, can lead to feelings of disconnection and homesickness (Aziz et al., 2020). Often, local peers and faculty members remain unaware of the extent of these challenges, which can contribute to further social divide and misunderstanding (Yakunina et al., 2013). Conversely, students who actively build peer networks, seek mentorship, and engage with support services tend to report lower levels of acculturative stress and higher levels of psychological well-being, highlighting the importance of social integration for their success and mental health (Ali et al., 2024; Kristiana et al., 2022). This highlights how building a supportive community and fostering inclusive environments are essential strategies to help IMSs navigate their unique challenges and thrive academically, socially, and emotionally. Moreover, communication barriers are a significant hurdle for students coming from non- English-speaking backgrounds (Hamad et al., 2025). These challenges not only impede their ability to interact effectively with patients during clinical practice but also hinder understanding 5 of lectures, participation in discussions, and preparation for exams, thereby impacting their academic success (Li et al., 2024; Sheik et al., 2022; Yates et al., 2016; Wang & Pan, 2022). Financial and Systemic Hurdles Financial strain is also a major systemic barrier for IMSs. Unlike domestic students, IMSs typically have limited access to scholarships, financial aid, or federal loans. In the United States, fewer than half of medical schools even accept international applicants, and those that do often provide minimal funding options to support IMSs (Datta & Miller, 2012). The reliance on private loans with U.S. co-signers and the inability to work freely due to visa restrictions intensify financial stress (Mori, 2000). In addition to financial strain, systemic hurdles and immigration policies often compound IMSs challenges. For example, after graduation, IMSs must navigate complex visa processes to secure residency placements. Despite meeting academic and examination requirements, many face rejection or bias in residency applications due to their citizenship status (Datta & Miller, 2012). Other systemic hurdles, such as perceived or overt discrimination, can exacerbate acculturative stress and hinder adjustment (Ali et al., 2024; Shan et al., 2020). Studies show that perceived discrimination correlates with increased psychological distress and reduced academic performance among IMSs (Yamada et al., 2014). As IMSs face these challenges while studying medicine abroad, they depend on certain supports to overcome them. These will be discussed in the next section. Support Systems and Coping Strategies IMSs employ a diverse array of strategies to effectively navigate the multifaceted challenges they face in a new academic and cultural environment. Some key approaches involve peer support networks, mentorship programs, and cultural exchange opportunities, which have 6 been shown to significantly improve academic performance and foster a sense of belonging and integration among IMSs (Malau-Aduli, 2011; Smith & Khawaja, 2011; Yakunina et al., 2013). These initiatives not only promote academic success but also help IMSs develop personal resilience and intercultural competence. Furthermore, institutions that offer structured support systems—such as culturally competent counseling and comprehensive mental health services—play a crucial role in enhancing students' well-being (Ammigman et al., 2024; Kristiana et al., 2022; Sakiz & Jencius, 2024). Such services create a supportive environment that bolsters students' mental health and academic persistence. Research also emphasizes the importance of dedicated programs or student associations tailored to IMSs. These organizations provide vital communal spaces where students can share experiences, seek guidance, and build lasting social networks, which are instrumental in alleviating stress and feelings of loneliness (Huhn et al., 2016; Sisavath, 2021). Also, financial support—where sourced from families or institutional scholarships and grants—serves as a critical protective factor, alleviating financial burdens that can exacerbate stress during the transition period (Datta & Miller, 2012). Collectively, these strategies contribute to creating a more inclusive, supportive, and empowering environment for IMSs, ultimately aiding in their academic success and personal well-being. Unique U.S. Context While IMSs worldwide face similar challenges, those studying in the United States experience unique pressures due to the country’s high tuition costs, immigration laws, and sociopolitical climate (Datta &Miller, 2012). The U.S. offers fewer pathways to permanent residency compared to nations like Canada and Australia, leading to persistent uncertainty (Choudaha, 2017). Moreover, experiences of racial discrimination and xenophobia—exacerbated 7 during times of political or social unrest—can further threaten students’ sense of belonging (Lee & Rice, 2007). These distinctions highlight the need for U.S.-specific research to understand IMSs’ psychosocial experiences. Rationale for This Study Despite knowledge of the challenges IMSs globally face and their adaptive strategies, research focused on IMSs in the U.S. remains limited. Additionally, existing literature largely emphasizes quantitative measures of academic outcomes, acculturative stress, and other mental health indicators, with few studies exploring the lived experiences of IMSs and the psychosocial support systems that facilitate their adaptation (Greenstein & Davis, 2019; Joaquim et al., 2024). This study aims to fill these two gaps in the existing literature by contributing to research on IMSs in the United States and expanding qualitative insights into their experiences. Given the unique challenges of navigating rigorous medical education while adapting to life in a new country, a methodology that prioritizes exploration and theory development is warranted. Grounded theory allows for a rich, participant-centered understanding of IMSs’ experiences and provides the foundation for generating context-specific insights and practical recommendations (Glaser & Strauss, 1967; Charmaz, 2014). Beginning “from the ground up” allows the researcher to prioritize the perspectives of IMSs and develop a theory that emerges directly from their stories (Glaser & Strauss, 1967). Through this approach, the study seeks to enhance both academic knowledge and institutional practices that better assist IMSs throughout their journeys (Charmaz, 2014). Although the study mainly focuses on understanding the experiences of IMSs in the United States, the author initially aimed to take a global view. The next chapter, Chapter 2, examines the diverse experiences of IMSs across different countries and cultures to identify 8 shared challenges and unique issues they face worldwide. Chapter 3 describes the methodology for the original grounded theory research. Chapter 4 presents the findings of this study, providing a detailed understanding of IMSs’ experiences and practices in U.S. medical schools, and developing a theoretical framework to help create more responsive institutional policies and support programs. Finally, Chapter 5 discusses the implications of these findings for IMSs, medical schools, and healthcare providers who interact with or support this population. REFERENCES Acharya, J., & Sahani, S. (2022). Coping up with stress as a medical student. Journal of Nepal Medical Association, 60(248), 416-418. https://doi.org/10.31729/jnma.7449e Al-Haddad, M. (2024). International medical graduates: Defining the term and using it consistently. BMJ Global Health, 9(8), e015678. https://doi.org/10.1136/bmjgh-2024- 015678 Ali, Y. A., Hussein, R. S., Mostafa, N. S., & Manzour, A. F. (2024). Factors associated with acculturative stress among international medical students in an Egyptian university. BMC Medical Education, 24(1), 1009-10. https://doi.org/10.1186/s12909-024-05947-5 American Association of Colleges of Nursing. (2024). Nursing Shortage Fact Sheet. AACN. https://www.aacnnursing.org/news-data/fact-sheets/nursing-shortage American Medical Association (AMA). (n.d). About the International Medical Graduates Section (IMGS). https://www.ama-assn.org/member-groups-sections/international-medical- graduates/about-international-medical-graduates Ammigan, R., Veerasamy, Y. S., & Cruz, N. I. (2024). “It is always hard at the beginning:” Peer- to-peer Advice for International Students Transitioning to University Life in the US. Asaad, M., Erekat, K., & Rajesh, A. (2025). An in-depth analysis of the state laws that license international medical graduates without American residency training. The Journal of Surgical Research, 306, 524-532. https://doi.org/10.1016/j.jss.2024.12.029 Association of American Medical Colleges. (2023). The complexities of physician supply and demand: Projections from 2023 to 2034. AAMC. 10 Aziz, A., Mahboob, U., & Sethi, A. (2020). What problems make students struggle during their undergraduate medical education? A qualitative exploratory study. Pakistan Journal of Medical Sciences, 36(5), 1020-1024. https://doi.org/10.12669/pjms.36.5.2267 Bennett, R. J., Volet, S. E., & Fozdar, F. E. (2013). 'I'd say it's kind of unique in a way': The development of an intercultural student relationship. Journal of Studies in International Education, 17(5), 533-553. https://doi.org/10.1177/1028315312474937 Berry, J. W. (2006). Stress perspectives on acculturation. In The Cambridge Handbook of Acculturation Psychology (pp. 43-57). Cambridge University Press. Berry, J. W. (1980). Acculturation as varieties of adaptation. Acculturation: Theory, models and some new findings, 9, 25. Bound, J., Braga, B., Khanna, G., & Turner, S. (2021). The globalization of postsecondary education: The role of international students in the US higher education system. The Journal of Economic Perspectives, 35(1), 163-184. https://doi.org/10.1257/jep.35.1.163 Charmaz, K. (2014). Constructing grounded theory (2nd ed.). Sage. Chen, X., & Sun, H. (2024). The anxiety and depression of international medical students during COVID-19 pandemic: A cross-sectional study. Perspectives in Psychiatric Care, 2024, 1- 9. https://doi.org/10.1155/2024/2285597 Choudaha, R. (2017). Three waves of international student mobility (1999-2020). Studies in Higher Education (Dorchester-on-Thames), 42(5), 825- 832. https://doi.org/10.1080/03075079.2017.1293872 Datta, J., & Miller, B. M. (2012). International students in United States' medical schools: Does the medical community know they exist? Medical Education Online, 17(1), 15748- 3. https://doi.org/10.3402/meo.v17i0.15748 11 David, Y. N., & Issaka, R. B. (2021). Advancing diversity: the role of international medical graduates. The lancet. Gastroenterology & hepatology, 6(12), 980–981. https://doi.org/10.1016/S2468-1253(21)00376-9 Glaser, B. G., & Strauss, A. L. (1967). The discovery of grounded theory: Strategies for qualitative research. Aldine. Greenstein, T. N., & Davis, S. N. (2019). Methods of research on human development and families. SAGE Publications. Hamad, A. A., Mustaffa, D. B., Alnajjar, A. Z., Amro, R., Deameh, M. G., Amin, B., & Alkhawaldeh, I. M. (2025). Decolonizing medical education: A systematic review of educational language barriers in countries using foreign languages for instruction. BMC Medical Education, 25(1), 701-17. https://doi.org/10.1186/s12909-025-07251-2 Huhn, D., Huber, J., Ippen, F. M., Eckart, W., Junne, F., Zipfel, S., Herzog, W., & Nikendei, C. (2016). International Medical Students’ expectations and worries at the beginning of their medical education: A qualitative focus group study. BMC Medical Education, 16(1). https://doi.org/10.1186/s12909-016-0549-9 Institute of International Education Network. (2023). Open doors report on international educational exchange. IIE Network. Jiang, Q., Horta, H., & Yuen, M. (2024). High- and low-achieving international medical students' perceptions of the factors influencing their academic performance at Chinese universities. Medical Education Online, 29(1), 2300194- 2300194. https://doi.org/10.1080/10872981.2023.2300194 https://doi.org/10.1186/s12909-025-07251-2 12 Joaquim, T., Brimhall, A.S., Sewell, K., Lamson, A.L., Reed-Fitzke, K., Drake, M., & Anderson, G. (2024). Crossing borders: A Systematic Review of International Medical Students’ Experiences. [Unpublished Manuscript]. Kristiana, I. F., Karyanta, N. A., Simanjuntak, E., Prihatsanti, U., Ingarianti, T. M., & Shohib, M. (2022). Social support and acculturative stress of international students. International Journal of Environmental Research and Public Health, 19(11), 6568. https://doi.org/10.3390/ijerph19116568 Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. Springer Pub. Co. Lee, J. J., & Rice, C. (2007). Welcome to America?: International student perceptions of discrimination. Higher Education, 53(3), 381-409. https://doi.org/10.1007/s10734-005- 4508-3 Li, D., Han, Y., & Zheng, J. (2025). Negotiating language use in intercultural communication: Scaling practices of international medical students in a Chinese hospital. Language and Intercultural Communication, 1-16. https://doi.org/10.1080/14708477.2025.2481218 Lu, Y., Zhu, H., & Chen, J. (2022). Psychological resilience and academic performance in international medical students. Frontiers in Psychology, 13, 774-787. Malau-Aduli, B. S. (2011). Exploring the experiences and coping strategies of international medical students. BMC Medical Education, 11(40), 40-40. https://doi.org/10.1186/1472- 6920-11-40 McElvaney, O. J., & McMahon, G. T. (2024). International medical graduates and the physician workforce. JAMA: The Journal of the American Medical Association, 332(6), 490- 496. https://doi.org/10.1001/jama.2024.7656 13 McGrail, M. R., et al. (2019). Addressing regional shortages through international medical students. Australian Journal of Rural Health, 27(2), 123–130. Michalski, K., Farhan, N., Motschall, E., Vach, W., & Boeker, M. (2017). Dealing with foreign cultural paradigms: A systematic review on intercultural challenges of international medical graduates. PloS One, 12(7), e0181330- e0181330. https://doi.org/10.1371/journal.pone.0181330 Mori, S. C. (2000). Addressing the mental health concerns of international students. Journal of Counseling and Development, 78(2), 137-144. https://doi.org/10.1002/j.1556- 6676.2000.tb02571.x Oduwaye, O., Kiraz, A., & Sorakin, Y. (2023). A trend analysis of the challenges of international students over 21 years. SAGE Open, 13(4)https://doi.org/10.1177/21582440231210387 Olivas, M., & Li, C. (2006). Understanding stressors of international students in higher education: What college counselors and personnel need to know. Journal of Instructional Psychology, 33(3), 217. Organization for Economic Cooperation and Development. (2022). Education at a glance 2022. OECD Publishing. Pemberton, M., Gnanapragasam, S. N., & Bhugra, D. (2022). International medical graduates: Challenges and solutions in psychiatry. BJPsych International, 19(2), 30- 33. https://doi.org/10.1192/bji.2021.15 Picton, A., Greenfield, S., & Parry, J. (2022). Why do students struggle in their first year of medical school? A qualitative study of student voices. BMC Medical Education, 22(1), 100-100. https://doi.org/10.1186/s12909-022-03158-4 14 Rizwan, M., Rosson, N., Tackett, S., & Hassoun, H. (2018). Opportunities and challenges in the current era of global medical education. International Journal of Medical Education, 9, 111-112. https://doi.org/10.5116/ijme.5ad1.ce9a Sakız, H., & Jencius, M. (2024). Inclusive mental health support for international students: Unveiling delivery components in higher education. Global Mental Health, 11, e8. https://doi.org/10.1017/gmh.2024.1 Schut, R. A. (2022). Disaggregating inequalities in the career outcomes of international medical graduates in the United States. Sociology of Health & Illness, 44(3), 535- 565. https://doi.org/10.1111/1467-9566.13433 Schwartz, S. J., & Zamboanga, B. L. (2008). Testing berry's model of acculturation: A confirmatory latent class approach. Cultural Diversity & Ethnic Minority Psychology, 14(4), 275-285. https://doi.org/10.1037/a0012818 Shah, P., Sapkota, A., & Chhetri, A. (2021). Depression, anxiety, and stress among first-year medical students in a tertiary care hospital: A descriptive cross-sectional study. Journal of Nepal Medical Association, 59(236), 346-349. https://doi.org/10.31729/jnma.6420 Shan, C., Hussain, M., Sargani, G. R., & Reddy, S. V. (2020). A mix-method investigation on acculturative stress among Pakistani students in China. PloS One, 15(10), e0240103- e0240103. https://doi.org/10.1371/journal.pone.0240103 Shaurya Shah, S. (2022). Experience sharing: First and second year of a medical college. Journal of Nepal Medical Association, 60(245), 106-108. https://doi.org/10.31729/jnma.7085 Sheikh, A. M., Sajid, M. R., Bakshi, E. N., Khan, A. U., Wahed, M. M., Sohail, F., & Sethi, A. (2022). The perceptions of non-native medical students towards language barrier on 15 clinical teaching and learning: A qualitative study from Saudi Arabia. Medical Science Educator, 32(4), 865-872. https://doi.org/10.1007/s40670-022-01579-w Smith, R. A., & Khawaja, N. G. (2011). A review of the acculturation experiences of international students. International Journal of intercultural relations, 35(6), 699-713. van der Zee, K., & van Oudenhoven, J. P. (2022). Towards a dynamic approach to acculturation. International Journal of Intercultural Relations, 88, 119- 124. https://doi.org/10.1016/j.ijintrel.2022.04.004 Wang, J., & Pan, L. (2022). Role of resistance to innovation, lack of intercultural communication, and student interest on the student demotivation results towards the English education system. Frontiers in Psychology, 13, 922402- 922402. https://doi.org/10.3389/fpsyg.2022.922402 World Health Organization. (2023). Global strategy on human resources for health: Workforce 2030. WHO Press. Yakunina, E. S., Weigold, I. K., Weigold, A., Hercegovac, S., & Elsayed, N. (2013). International students' personal and multicultural strengths: Reducing acculturative stress and promoting adjustment. Journal of Counseling and Development, 91(2), 216- 223. https://doi.org/10.1002/j.1556-6676.2013.00088.x Yamada, Y., Klugar, M., Ivanova, K., & Oborna, I. (2014). Psychological distress and academic self-perception among international medical students: The role of peer social support. BMC Medical Education, 14(1), 256. https://doi.org/10.1186/s12909-014-0256- 3 16 Yates, L., Dahm, M. R., Roger, P., & Cartmill, J. (2016). Developing rapport in inter- professional communication: Insights for international medical graduates. English for Specific Purposes, 42, 104-116. CHAPTER 2: CROSSING BORDERS: A SYSTEMATIC REVIEW OF INTERNATIONAL MEDICAL STUDENTS’ EXPERIENCES In response to the swift decrease in healthcare workers, medical schools globally are seeking to boost enrollments to counter these declines and fulfill their countries' healthcare requirements. Attempts to increase enrollment have led various countries to host a growing number of international students. Countries like the US, China, Australia, New Zealand, and Germany commonly host international students for their medical education/training (AAMC, n.d; Huhn et al., 2015; Lu et al., 2022; McGrail et al., 2019). Data from the Organization of Cooperation and Economic Development (OECD, 2013) suggests that one out of every five students enrolled in higher-level research programs, including medical school, was international. Specifically, within the United States, other statistics suggest an annual increase of up to 15% of international students in higher-level research programs, including medical schools, since 2000, resulting in over 1 million international students in the country (Institute of International Education Network, 2023). Studying abroad offers many benefits, such as developing intercultural competency and preparing students for a global workforce. It also has a positive impact on international students, as well as host students, by increasing awareness of different worldviews and fostering appreciation and respect for differences (Bennett et al., 2013). However, being an international student also comes with unique challenges compared to studying in one's home country. According to Berry’s (1980) acculturation model, a change process typically occurs when two or more cultures come in contact with each other. This process consists of four strategies (assimilation, separation, integration, and marginalization), with integration seen as the most adaptive approach, allowing immigrants to combine preferred traits from different social systems 18 while retaining their cultural background (van der Zee & van Oudenhoven, 2022). As international students, more specifically IMSs, encounter a new sociocultural system, they often face different types of acculturative challenges and may encounter varying degrees of acculturative stress as they try to cope with their new social system while striving to maintain their own sense of identity. Additionally, like what van der Zee and van Oudenhoven (2022) propose about acculturation, the interaction between immigrants and non-immigrants involves not only cultural adaptations but also cognitive, behavioral, and emotional adjustments and challenges that are a part of cross-cultural interactions. Along with financial challenges, international students often have to navigate several other challenges as they integrate into the host country, including a) cultural challenges such as language barriers and prejudices (Byrne et al., 2019); b) psychological challenges such as psychological stress (Acharya & Sahani, 2022), anxiety, depression (Shah et al., 2021), and burnout (Shaurya Shah, 2022); c) social challenges such as distance from family support and developing relationships in country of study (Aziz et al., 2020); and d) immigration barriers (Datta & Miller, 2012). These challenges are in addition to the significant demands already associated with the rigor of being a medical student, like issues with time management and navigating academic difficulty (Aziz et al., 2020; Picton et al., 2022). As a result, the number of international matriculants in US medicine is significantly low, with only 0.6% of matriculants being international (Virji, 2021). Consequently, depending on how IMSs manage these challenges, this can negatively impact their acculturation experiences and, inadvertently, their quality of life (QoL) in the host country. QoL in this article refers to “an individual's perception of their position in life within the context of the culture and value systems in which they live and 19 in relation to their goals, expectations, standards, and concerns” (WHO, 2012, p. 11). Considering the unique challenges of studying medicine abroad and the necessity for adaptable interventions for IMSs and medical schools, this systematic review explores the research question: How do psychosocial support systems and resources influence international students’ experiences in medical school? Method In the current review, the methodological framework and reporting procedures were guided by Cooper’s (2010) research synthesis approach and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA; Moher et al., 2009) guidelines. Cooper’s (2010) approach to research synthesis is used to analyze and integrate results into different topic areas. More specifically, the systematic review was based on the following steps: 1) Formulating the problem, 2) Searching the literature, 3) Gathering information from studies, 4) Evaluating the quality of studies, 5) Analyzing and Integrating the outcome of studies 6) Interpreting the evidence and, 7) Presenting the results. Article Search Strategy and Selection The present search included studies from these databases: PubMed via Medline, CINAHL, and PsycINFO via EBSCOhost. They were selected because they focused on medical education, education in general, and psychology. The primary investigator (TJ) and another author (KS), a former librarian, developed the search strategy. The search strategy included controlled vocabulary and keywords for international medical students and psychosocial resources (see Table 1). The initial search was conducted in PubMed using MeSH terms and then translated to controlled vocabulary for the other databases (CINAHL and PsycINFO). 20 Limitations such as date, peer review, geography, or language were not set on the search. All the studies resulting from the search were loaded into Covidence (www.covidence.org), which identified and removed any duplicates. Two reviewers (TJ & GA) independently screened the titles and abstracts of the articles to determine their eligibility for the current review. The criteria for suitability were (a) articles written in English, (b) peer-reviewed, (c) involved human participants, and (d) about international medical students (non-resident students who have completed prior education in another country and only entered a host country to further their medical education). Although more prominent in the literature, one specific exclusion criterion was International Medical Graduates (IMGs), those who already completed their primary medical qualification in a different country and joined the workforce of a host country to practice medicine (Al-Haddad, 2024). Articles such as commentaries, reviews, and editorials were also excluded since they were not considered empirical articles. All titles and articles were reviewed by two of the authors (TJ and GA). To ensure consistency in the initial screening process, 10 articles were selected and independently reviewed based on their titles and abstracts. Subsequently, fidelity checks were conducted by comparing the results, and any discrepancies between the reviewers were resolved through discussion until a consensus was reached. Articles that passed the initial screening were then included in the full- text review. Additionally, during the full-text review, any differences in opinion between the reviewers were discussed until a consensus was reached on which articles met the inclusion/exclusion criteria and were eligible for extraction and synthesis. The PRISMA flow diagram (Figure 1) provides a record of the article selection process for the review, and a systematic review protocol is available online (https://osf.io/6cnmr/files/osfstorage/66670984d835c430ab4ce240). 21 Data Extraction and Synthesis Data extraction was done using Covidence and Microsoft Excel. Extracted data elements include author(s), last name(s), year of publication, country where the study was conducted, population size and characteristics, sampling method, study design, outcomes, and findings. Data extraction and synthesis were performed solely by the primary investigator (TJ). Data were synthesized using narrative synthesis methods (Popay et al., 2006). Quality assessments were also made using the LEGEND (Let Evidence Guide Every New Decision) cross-sectional and longitudinal (quantitative) appraisal forms, and qualitative and mixed-method appraisal forms as described in Clark et al. (2009). Results An initial literature search conducted between September 2023 and February 2024 produced 577 results. The comprehensive search strategy was carried out using a PRISMA flowchart (Moher et al., 2009; see Figure 1). After removing duplicates, 503 articles' titles and abstracts were reviewed for eligibility by two reviewers (TJ and GA). A total of 45 articles were fully reviewed for population criteria, publication type, and the inclusion of a discussion on IMSs. Initially, 35 articles met the inclusion criteria and were included in the final review; however, after an in-depth review, both reviewers agreed to omit three articles from the analysis because although they were call-to-action editorials and reviews about IMSs’, they were not studies with empirical designs. Therefore, a total of 32 articles were included in the final review. The studies included (see Table 2) were conducted in various countries: seven in Germany, four in China, three in Israel and the Netherlands, two in Hungary, and Ireland, and one each in the Czech Republic, Peru, Cyprus, Ukraine, Romania, Turkey, New Zealand, Australia, and the Eastern Caribbean. Additionally, two studies were conducted concurrently in two countries, one 22 in Australia and New Zealand and the other in Germany and Hungary. It's worth noting that although none of the studies included were conducted in the United States, four of them (Abramovitch et al., 2000; Byrne et al., 2019; Gradiski et al., 2022; Kovatz et al., 2006) involved American students studying abroad. While they all included IMSs, the studies included had different purposes and methodological designs. Twenty-three were quantitative, six were qualitative explorations, and three were mixed-method. In each study, IMSs’ countries of origin spanned different continents. Interestingly, over half of the studies had more female participants than male, and regarding the students’ years in medical school, more than 36% of the studies focused specifically on IMSs in the early phases of their medical education, over 48% of the studies included participants from their first to final year in medical school, while the remaining studies did not specify the students' years. The quality assessment was evaluated based on the LEGEND appraisal forms for cross- sectional and longitudinal quantitative studies, qualitative studies, and mixed-method studies. The evaluation criteria were based on three categories: the validity, reliability, and applicability of the articles. Regarding validity, things like the appropriateness of the study method used, the use of objective and unbiased measuring instruments in quantitative studies, and freedom from conflicts of interest were checked. Regarding reliability, sample size, appropriateness of analysis methods and the significance of the results (statistical and clinical) were evaluated. Lastly, in terms of applicability, the articles were evaluated based on how well the results can be applied to the author’s population of interest, so in this review, how well the results can be applied to IMSs. Articles that met the three criteria categories were considered Good Quality, while those that 23 were missing one or two qualities were considered lesser quality, and those missing all three were considered to be not valid, reliable, or applicable articles. For the included articles, a higher percentage (56.25%) of articles had good quality compared to those with lesser quality (43.75%). None of the articles was not valid, reliable, or applicable since, in this review, all the included articles are applicable to IMSs. Of the twenty- three quantitative studies, eleven were deemed good quality, and twelve were of lesser quality. Among the six qualitative studies, four were of good quality, while two were deemed lesser quality. Additionally, the three mixed-method studies were all determined to be of good quality (see Table 3). Key factors influencing IMSs’ experiences in medical school After analyzing all 32 identified articles, it was evident that acculturation significantly affected the QoL of IMSs, especially as they dealt with the associated challenges. The presence of social support systems, including peer support, faculty support, family support, and access to resources such as welcoming/orientation programs, was found to aid IMSs in managing these challenges while maintaining a healthy QoL (see Table 3). Acculturation The findings of this systematic review highlight acculturation as a major theme. As defined by Berry's (1980) bi-dimensional model, acculturation involves the extent to which immigrants want to maintain their ethnic culture and interact with the majority group. In this systematic review, nearly every study discussed the challenges faced by IMSs as they went through the acculturation process. These challenges can be divided into four categories: a) language and communication, b) stress, anxiety, depression, and coping, c) economics, and d) 24 discrimination and prejudice. This section will describe the findings associated with each category. Language and Communication. This component describes IMSs’ ability to communicate with members of the host country in both academic and non-academic settings. One study showed that IMSs viewed communication as the most valuable personal feature of a doctor (Khrystenko et al., 2022), even though they also needed to navigate a lot of communication barriers including challenges in learning the host country's language and colloquial language (Byrne et al., 2019; Huhn et al., 2016), and understanding the medical system and medical terminology of the host country (Huhn et al., 2016; Malau-Aduli et al., 2011). In a mixed-method study, IMSs expressed concerns about how communication difficulties not only impacted their integration into the host country's educational system but also affected their performance in oral and practical medical examinations (including the collection of patient history, evaluation of bedside manner, and Objective Structured Clinical Exams (OSCEs)) (Malau-Aduli et al., 2011). Multiple studies found that language and communication skills played a significant role in student adaptation (Lenz et al., 2018; Watkins et al., 2022; Yilmaz et al., 2020). Consequently, the more comfortable students felt communicating in the host country's official language, the less acculturative stress they experienced (Iorga et al., 2020). Stress, anxiety, depression, and coping. In this review, although only a few articles specifically used the term acculturative stress (Iorga et al., 2020; Watkins et al., 2022), there was still a significant relationship between the stress that IMSs experienced as they navigated medical school and adverse mental health outcomes such as anxiety and depression. Together, stress, anxiety, and depression impacted IMSs’ integration into the host country, especially their acculturation strategies. Fourteen articles discussed IMSs managing anxiety, depression, and 25 stress-related issues like burnout and coping (Abramovitch et al., 2000; Akhtar et al., 2019; Gradiski et al., 2022; Hillis et al., 2010; Huhn et al., 2018; Iorga et al., 2020; Kovatz et al., 2006; Lu et al., 2022; Lewis, 2021; Naser et al., 2022; Watkins et al., 2022; Yilmaz et al., 2020; Yuan et al., 2021, 2023; Zhou et al., 2023b). Furthermore, one article showed that exam stress had an impact on physiological health (Yilmaz et al., 2020). As IMSs navigated these mental health issues, it was not uncommon for them to also experience burnout (Lewis, 2021) and lower self-esteem than domestic students (Naser et al., 2022). However, in responding to these challenges, IMSs also had some agency. They could use negative coping styles (like suppression and reactive coping) or adaptive coping styles (such as seeking counseling or medical services). When negative coping styles were used, anxiety and depression symptoms were more prominent (Akhtar et al., 2019). On the other hand, when adaptive styles were employed, it was associated with reduced stress, anxiety, and depression (Abramovitch et al., 2000). In addition to acculturative stress, IMSs faced challenges with discrimination, prejudice, and managing financial and immigration concerns. Discrimination and prejudice. Six articles discussed how IMSs faced discrimination and prejudice based on race and ethnicity from fellow students, faculty, administration, and patients (Iorga et al., 2020; Watkins et al., 2022; Byrne et al., 2019; Yilmaz et al., 2020). IMSs reported feeling like an "other" or "foreigners" (Astfalk & Muller-Hilke, 2018, p. 6), and reported being treated differently because of their race and ethnicity (Iorga et al., 2020). One study even highlighted how IMSs felt like they were not liked by some academic advisors because they had come to “take” resources such as scholarships from medical students in the host country (Yilmaz et al., 2020, p. 68). These experiences impacted how IMSs adjusted to the host country and were correlated with increased acculturative stress. 26 Economic needs. Six articles also examined the economic needs of international medical students, including financial and immigration needs (Chambergo-Michilot et al., 2020; Yuan et al., 2021; Khyrstenko et al., 2022; Riemenschneider et al., 2016; Watkins et al., 2022; Huhn et al., 2016; Malau-Aduli et al., 2011). These articles revealed that due to the high cost of medical school and limited access to financial aid, international medical students often have to consider how they will pay their fees and where they will find financial support. Huhn et al. (2016) also emphasized how immigration policies can impact the successful integration of international medical students into the host country during the acculturation process. Consequently, this review emphasizes the importance of psychosocial support systems and resources in addressing the challenges faced by IMSs and improving QoL in medical school. This review showed that when IMSs utilized available psychosocial support systems and programs, their levels of acculturative stress were reduced, and their integration into the host country significantly improved. Social support that influences IMSs’ experiences in medical school To overcome the challenges that IMSs face while acculturating, Byrne et al. (2019) concluded that it was important for international students to have relationships where they felt comfortable being themselves and practicing their culture. Peer support was identified as the most common and effective form of psychosocial support for IMSs. Although one study showed no significant link between perceived social support and mental health conditions like anxiety and depression (Yuan et al., 2021), ten articles emphasized its importance and benefits for IMSs (Abramovitch et al., 2000; Astfalk & Müller-Hilke, 2018; Jiang et al., 2023; LuLu et al., 2022; Malau-Aduli et al., 2011; Maffoni et al., 2021; Sykes & Eden, 1985; Yamada et al., 2014; Yuan et al., 2023; Zhou et al., 2023b). These articles highlight that peer support helped protect IMSs 27 from psychological stress and poor academic performance (Yamada et al., 2014; Zhou et al., 2023b), buffered transitional stress (Sykes & Eden, 1985), which was positively correlated with psychosocial health. Peer support helped IMSs cope and bounce back from examination failure in their medical training (Jiang et al., 2023) and helped them navigate mental health diagnoses like anxiety and depression (Abramovitch et al., 2000; LuLu et al., 2022; Maffoni et al., 2021; Yuan et al., 2023). Another study showed that IMSs in the mixed international groups with Dutch students outperformed the students in the homogenous Dutch groups in achieving excellent performance scores (Zhou et al., 2020). This shows that the integration of IMSs with domestic students benefits both IMSs and domestic students. However, although peer support was found to be the most impactful form of psychosocial support during the acculturation process for IMSs, some studies still showed that sometimes IMSs require extra support to connect with domestic students since they are more likely to interact with peers from the same nationality (Astfalk & Müller- Hilke, 2018; Malau-Aduli et al., 2011; Zhou et al., 2023a). Also, in the medical school system, administrative support and faculty support were found to help IMS acculturate. Administrative support was found to be related to lower acculturative stress (Iorga et al., 2020); however, insufficient administrative support impacted the adjustment of IMSs (Abramovitch et al., 2000). Two articles discussed the importance of faculty support for IMSs in managing stress (Maffoni et al., 2021; Yamada et al., 2014). In all, greater support from students, faculty, and administrators results in a greater sense of satisfaction in medical school (Lewis, 2021). Outside of support from the school system, other social support systems that IMSs leaned on as they walked toward integrating into the host country included family support and support from romantic partners. Three articles discussed the importance of family support (Gradiski et 28 al., 2022; Malau-Aduli et al., 2011; Maffoni et al., 2021), pointing to its role in promoting well- being for IMSs in stressful situations (Maffoni et al., 2021), addressing burnout (Gradiski et al., 2022), and providing financial assistance (Malau-Aduli et al., 2011). Surprisingly, support from romantic partners did not significantly impact the quality of life of IMSs in studies that addressed it (Gradiski et al., 2022; Yamada et al., 2014). Social support systems such as peer support, faculty and administrative support, and support from family play a significant role in IMSs’ experiences of adjusting to a new culture while trying to maintain their well-being and quality of life. However, as discussed below, these support systems sometimes also need to be reinforced by targeted programs specifically designed to address their specific needs. Psychosocial resources that influence IMSs’ experiences in medical school Psychosocial resources in this review refer to resources that include social support and mental health strategies to help IMSs better integrate into the host country. In efforts to improve the acculturation process and help IMSs better manage or overcome the challenges associated with acculturation, the findings in this study highlighted some programs that medical schools developed specifically for IMSs. Three articles (Herman-Werner et al., 2018; Marmon et al., 2018; Oláh et al., 2022) discussed such programs. One program involving both international and domestic students showed that IMSs experienced lower levels of perceived stress after participating in a "buddy/tandem" program. Interestingly, domestic students reported higher levels of perceived stress after the program (Herrmann-Werner et al., 2018). The program began with an introductory meeting where domestic and international students met, paired up through casual encounters such as studying together or engaging in social activities, took part in an 29 international potluck dinner, and shared their experiences with the program (Herrmann-Werner et al., 2018). Similarly, another program involving senior medical students and faculty consisted of a welcome event for IMSs, orientation sessions to help students adjust to the study program, teaching infrastructures, and student life, as well as language training on medical communication and bedside manner (Marmon et al., 2018). During the program, medical students reported that they found the sessions on first-semester content, using online platforms, ward communication, and taking a patient medical history and physical examination to be the most helpful. The programs were aimed at students in the early stages of their medical education. Additionally, in a study evaluating online mental health services during the COVID-19 pandemic, Oláh et al. (2022) found that IMSs preferred brief stress management techniques in audio format and were particularly interested in methods to reduce distress and improve study skills rather than mental health apps. Interestingly, in this study, despite the need for help coping with the mental health effects of the pandemic, their results showed IMSs preference for stress reduction and study improvement techniques. Discussion The present systematic review examined how psychosocial support systems and resources help promote IMSs’ QoL in medical school. The results showed that although the acculturation process that IMSs have to navigate is not without challenges, with adequate psychosocial support and resources, IMSs can integrate into the host country of their medical education while still maintaining a healthy quality of life. While the acculturation experiences of IMSs may vary depending on their background, similarities or differences between their country and host country, and their acculturation strategies (Berry, 2005), this review highlights the 30 common barriers IMSs have to overcome influence the acculturation experience. Some of these barriers and challenges include language and communication barriers, stress, anxiety and depression, discrimination and prejudice, and economic needs such as financial and immigration support available to IMSs. These challenges can significantly impact IMSs' quality of life in medical school, affecting their sense of satisfaction, success, and fulfillment. To address the challenges IMSs face and improve QoL in medical school, this review emphasizes the importance of social support systems and resources. Peer support, faculty/administrative support, and support from family were vital for IMSs in adapting to the host country and maintaining a healthy QoL. Among these, peer support was found to have the most significant impact. Peer support helped IMSs in several ways: 1) protecting them from psychological stress and poor academic performance, 2) aiding in coping with and recovering from exam failure, 3) buffering transitional stress, and 4) assisting with navigating mental health issues such as depression and anxiety. Additionally, administrative and faculty support from medical institutions played a crucial role in reducing acculturative and school-related stress for IMSs. Some institutions even developed tailored programs to meet the specific needs of IMSs, which helped reduce their perceived stress by facilitating interactions with domestic students, providing language and communication training, and offering mental health services. These factors collectively contributed to further integrating IMSs into the host country for their medical education, ultimately leading to improved outcomes and a healthier QoL. These findings align with Berry’s (1980) acculturation model, which outlines four strategies—integration, assimilation, separation, and marginalization—through which individuals navigate cultural adaptation, with integration widely recognized as the most adaptive approach (van der Zee & van Oudenhoven, 2022). Evidence of integration appeared when IMSs 31 described maintaining their cultural identity while simultaneously forming meaningful relationships with host-country peers, faculty, and community members (Astfalk & Müller-Hilke, 2018; Byrne et al., 2019; Herman-Werner et al., 2018; Iorga et al., 2020; Maffoni et al., 2021; Watkins et al., 2022; Yilmaz et al., 2020; Yamada et al., 2014; Zhou et al., 2020). Instances of assimilation emerged in studies where students felt pressure to adopt Western academic norms— such as assertiveness, independence, and self-promotion—even when these norms conflicted with their values (Byrne et al., 2019; Yamada et al., 2014). Conversely, separation was reflected in students’ tendency to rely primarily on co- national peers, often choosing to remain within familiar cultural groups to cope with academic and social demands (Herman-Werner et al., 2018; Watkins et al., 2022; Zhou et al., 2020). Finally, elements of marginalization appeared when IMSs described feeling excluded or misunderstood by their host institutions, lacking both cultural connection and institutional support (Astfalk & Müller-Hilke, 2018; Maffoni et al., 2021). These findings collectively endorse Berry’s assertion that successful integration depends on both building relationships within the host country and preserving one’s cultural identity, which together provide the most effective way to lessen acculturative stress. Consequently, the review makes a significant contribution by identifying some of the greatest needs of IMSs, pinpointing effective support strategies adopted by IMSs and medical schools to address these needs, and suggesting areas for further exploration to improve support for IMSs during the acculturation process. This review also emphasizes the need for more studies to be conducted specifically in the United States, as none of the included studies were carried out in the U.S. Furthermore, the findings recommend that medical institutions develop programs to help IMSs acculturate better, maintain a good quality of life, and achieve academic success. 32 Recommendations To address the anticipated shortage of physicians by 2034 (AAMC, 2021), countries need to develop strategies to reduce these projections and ensure an adequate number of healthcare workers to meet the nations' health requirements. IMSs represent a diverse group of future physicians who can help alleviate this projected shortage, address healthcare disparities and minority health issues, and deliver medical care to underserved populations (Datta & Miller, 2012). By focusing on supporting medical students, particularly IMSs, as they transition into the physician workforce and providing them with the necessary assistance to navigate the challenges of medical education until they become qualified physicians, countries can significantly contribute to maintaining an adequate number of healthcare workers to meet the impending physician shortage. Support from medical school programs and boards helps to ensure that IMSs graduate medical school successfully and proceed to residency programs where they can contribute to the physician workforce and alleviate this projected shortage. Due to IMSs’ global perspective, they might be especially suited for addressing healthcare disparities and minority health issues, improving healthcare accessibility, and delivering medical care to often underserved populations (Datta & Miller, 2012). We recommend that medical school programs better support the IMSs in the following ways. First, for students in the beginning phases of their medical education, medical schools can implement screening processes to evaluate the levels of acculturation individual students might need to undergo in medical school. These assessments can then be taken at the end of each year in medical school to assess how IMSs are acculturating in the host country. For example, scales like the Acculturative Stress Scale for International Students (ASSIS) discussed in Sandhu & Asrabadi (1994) might be utilized or developed to assess IMSs’ acculturative stress over time. 33 This will help tailor support to those students who might need it the most. Second, it is important to develop more psychosocial programs that are specifically designed to address the needs of IMSs and help them overcome the challenges they face while pursuing their studies. For example, a buddy/tandem program similar to the one developed by Herman-Werner et al. (2018) could be implemented. This program paired IMSs with domestic students, allowing them to participate in casual activities together, such as preparing for an exam or sharing a meal at an international potluck dinner. Medical schools could consider developing such programs to help IMSs address cultural differences and language difficulties and to increase social support due to the personal nature of these programs. These programs can then be tested for their effectiveness with IMSs. Also, due to the lack of research studies addressing the needs of IMSs specifically in the United States compared to other parts of the world, we recommend that medical schools in the United States that admit IMSs adopt these strategies to better support the IMSs in their programs during the acculturation process and in maintaining their quality of life. Even though there is currently limited infrastructure or larger governing bodies specifically addressing the needs of IMSs, possibly due to their small percentage in the United States, we recommend that medical school programs begin developing in-house programs that include components like identifying incoming IMSs, matching them with other IMSs or domestic peers or faculty, arranging social gatherings like an international potluck dinner and providing language training on medical communication and bedside manner in the host country. These initiatives, though seemingly small, can make a significant difference in the experiences of IMSs. Lastly, we recommend that more research on the different types of support systems, such as peer support, family and romantic partner support, faculty and administrative support, and 34 psychosocial programs, be conducted to test their specific effects on the acculturation process for IMSs. A better understanding of how the different psychosocial support systems help IMSs will not only assist the students themselves but may also help the medical system better support their IMSs. These studies can be quantitative, qualitative, or mixed-method designs. Limitations Although the current review provides important contributions to the literature, there are important limitations to consider. Firstly, the synthesis of the articles included in this review is based on studies from different countries, even though medical education systems, structures, and requirements often differ depending on the country. While this systematic review offers a more comprehensive and worldwide perspective on IMSs, some findings may be more applicable to the country where the study was conducted. Secondly, the results were not quantitatively analyzed (e.g., meta-analysis), which might have generated more depth and rigor in understanding how social support affects the quality of life of IMSs. Lastly, not all databases that may have had articles meeting the criteria were included in this study (e.g., ERIC), which might have contained other educational-related literature. However, this review emphasizes the specific challenges IMSs encounter and the psychosocial support/resources crucial for their successful integration and well-being in the host country. Recognizing key aspects of the acculturation process for IMSs underscores the need for more evidence-based research and support strategies within medical schools Conclusion The decision to study abroad presents several challenges to IMSs, including acculturative stress and difficulties adjusting to the host country's environment (Smith & Khawaja, 2011). As IMSs navigate the multidimensional process of acculturation and adaptation to the host country, 35 it is important for medical schools that admit IMSs to pay attention to the challenges IMSs may face while integrating into the school and host country and consider ways they can support their IMSs through ensuring that they have access to support systems and resources. Supporting IMSs means supporting future doctors and might just be one way that countries begin addressing the impending shortage of physicians facing countries within the coming years. REFERENCES References marked with an asterisk indicate studies included in the systematic review. *Abramovitch, H., Schreier, A., & Koren, N. (2000). American medical students in Israel: Stress and coping - a follow-up study. Medical Education, 34(11), 890- 896. https://doi.org/10.1046/j.1365-2923.2000.00677.x Acharya, J., & Sahani, S. (2022). Coping up with stress as a medical student. Journal of Nepal Medical Association, 60(248), 416-418. https://doi.org/10.31729/jnma.7449e Al-Haddad, M. (2024). International medical graduates: Defining the term and using it consistently. BMJ Global Health, 9(8), e015678. https://doi.org/10.1136/bmjgh-2024- 015678 *Akhtar, M., Herwig, B. K., & Faize, F. A. (2019). Depression and Anxiety among International Medical Students in Germany: The Predictive Role of Coping Styles. JPMA. The Journal of the Pakistan Medical Association, 69(2), 230-234. American Medical Association (AMA). (n.d). About the International Medical Graduates Section (IMGS). https://www.ama-assn.org/member-groups-sections/international- medical-graduates/about-international-medical-graduates Association of American Medical Colleges (AAMC). (2020). The road to becoming a doctor. https://www.aamc.org/media/36776/download Association of American Medical Colleges (AAMC). (2021). The complexities of physician supply and demand: Projections From 2019 to 2034. https://www.aamc.org/media/54681/download?attachment Association of American Medical Colleges (AAMC). (n.d). The road to becoming a doctor. https://www.aamc.org/media/36776/download 37 *Astfalk, T., & Müller-Hilke, B. (2018). Same same but different–A qualitative study on the development and maintenance of personal networks among German and international medical students. GMS Journal for Medical Education, 35(5). https://doi.org/10.3205/zma001204 Aziz, A., Mahboob, U., & Sethi, A. (2020). What problems make students struggle during their undergraduate medical education? A qualitative exploratory study. Pakistan Journal of Medical Sciences, 36(5), 1020-1024. https://doi.org/10.12669/pjms.36.5.2267 S Balan, R. (2022, October 4). What are the medical school entry requirements in Europe and the US? Studyportals. Retrieved May 29, 2024, from https://www.mastersportal.com/articles/1801/what-are-the-medical-school-entry- requirements-in-europe-and-the-us.html Bennett, R. J., Volet, S. E., & Fozdar, F. E. (2013). 'I'd say it's kind of unique in a way' : The development of an intercultural student relationship. Journal of Studies in International Education, 17(5), 533-553. https://doi.org/10.1177/1028315312474937 Berry, J. W. (1980). Acculturation as varieties of adaptation. Acculturation: Theory, models and some new findings, 9, 25. Berry, J. W. (2003). Conceptual approaches to acculturation. American Psychological Association. Berry, J. W. (2005). Acculturation: Living successfully in two cultures. International journal of intercultural relations, 29(6), 697-712 *Byrne, E., Brugha, R., & McGarvey, A. (2019). ‘A melting pot of cultures’–challenges in social adaptation and interactions amongst international medical students. BMC medical education, 19, 1-14. https://doi.org/10.1186/s12909-019-1514-1 38 *Chambergo-Michilot, D., Muñoz-Medina, C. E., Lizarzaburu-Castagnino, D., León-Jiménez, F., Odar-Sampé, M., Pereyra-Elías, R., & Mayta-Tristán, P. (2020). Migration to study in medical schools of Peru. Revista Peruana de Medicina Experimental y Salud Pública, 37, 81-86. https://doi.org/10.17843/rpmesp.2020.371.4695 Clark, E., Burkett, K., & Stanko-Lopp, D. (2009). Let evidence guide every new decision (LEGEND): An evidence evaluation system for point-of-care clinicians and guideline development teams. Journal of Evaluation in Clinical Practice, 15(6), 1054-1060. https://doi.org/10.1111/j.1365-2753.2009.01314.x Cooper, H. (2010). Research synthesis and meta-analysis: A step-by-step approach (4th ed). Sage. Datta, J., & Miller, B. M. (2012). International students in United States' medical schools: Does the medical community know they exist? Medical Education Online, 17(1), 15748- 3. https://doi.org/10.3402/meo.v17i0.15748 *Gradiski, I. P., Borovecki, A., Ćurković, M., San-Martín, M., Delgado Bolton, R.,C., & Vivanco, L. (2022). Burnout in international medical students: Characterization of professionalism and loneliness as predictive factors of burnout. International Journal of Environmental Research and Public Health, 19(3), 1385. https://doi.org/10.3390/ijerph19031385 *Herrmann-Werner, A., Junne, F., Stuber, F., Huhn, D., Nikendei, C., Seifried-Dübon, T., Zipfel, S., & Erschens, R. (2018). Reducing stress and promoting social integration of international medical students through a tandem program: Results of a prospective- program evaluation. International Journal of Environmental Research and Public Health, 15(9), 1959. https://doi.org/10.3390/ijerph15091959 39 *Hillis, J. M., Perry, W. R., Carroll, E. Y., Hibble, B. A., Davies, M. J., & Yousef, J. (2010). Painting the picture: Australasian Medical Student Views on wellbeing teaching and Support Services. Medical Journal of Australia, 192(4), 188–190. https://doi.org/10.5694/j.1326-5377.2010.tb03476.x *Huhn, D., Junne, F., Zipfel, S., Duelli, R., Resch, F., Herzog, W., & Nikendei, C. (2015). International medical students--a survey of perceived challenges and established support services at medical faculties. GMS Zeitschrift Für Medizinische Ausbildung, 32(1), Doc9- Doc9. https://doi.org/10.3205/zma000951 *Huhn, D., Huber, J., Ippen, F. M., Eckart, W., Junne, F., Zipfel, S., Herzog, W., & Nikendei, C. (2016). International Medical Students’ expectations and worries at the beginning of their medical education: A qualitative focus group study. BMC Medical Education, 16(1). https://doi.org/10.1186/s12909-016-0549-9 *Huhn, D., Schmid, C., Erschens, R., Junne, F., Herrmann-Werner, A., Möltner, A., Herzog, W., & Nikendei, C. (2018). A comparison of stress perception in international and local first semester medical students using psychometric, psychophysiological, and humoral methods. International Journal of Environmental Research and Public Health, 15(12), 2820. https://doi.org/10.3390/ijerph15122820 Institute of International Education Network. Open doors: Fast facts. Institute of International Education Network. (2011, 2023). http://www.iie.org/en/Research-and- Publications/Open-Doors/Data/Fast-Facts. *Iorga, M., Soponaru, C., Muraru, I.-D., Socolov, S., & Petrariu, F.-D. (2020). Factors associated with acculturative stress among international medical students. BioMed Research International, 2020, 1–9. https://doi.org/10.1155/2020/2564725 40 *Jiang, Q., Yuen, M., & Horta, H. (2023). Coping strategies of failing international medical students in two Chinese universities: A qualitative study. Teaching and Learning in Medicine, 36(2), 123–133. https://doi.org/10.1080/10401334.2023.2204077