A graduate level course offered to foreign medical graduates (FMGs) at Wayne State University in Michigan was developed after a needs assessment indicated the desirability of improving the speaking fluency, pronunciation, and cultural understanding of FMGs. It was found that weaknesses in those areas, which are not assessed in the Test of English as a Foreign Language (TOEFL) exam, can result in graduates gaining admittance to an American medical residency program in which they are unable to participate fully, in which they may perceive differences in treatment, and that can result in the inadequate medical treatment for patients. The course has three objectives: pronunciation, speaking in a medical context, and cultural issues related to physician-patient relationships. Methods by which each objective is taught are discussed. The following recommendations are offered: (1) departmental or self-selection may be more useful than the SPEAK test in identifying participants; (2) the course should be offered for one semester as early as possible during the first year of the training program; (3) it should be integrated into the residency program as much as possible to avoid scheduling complications; and (4) more research is needed on the relationship between FMGs and their colleagues and patients. (LB)