International Medical Graduates:
From Prevention to Remediation
Alan A Monavvari MD, MHSc, MSc, CHE, CCFP
Assistant Professor
Associate Director, Recruitment and Admission
Faculty/Presenter Disclosure
• Faculty:
Alan A. Monavvari
Perle Feldman
Anne Wideman
• Relationships with commercial interests:
– Not Applicable
Disclosure of Commercial
Support
• This program has received NO Commercial support
• This program has received NO in-kind support
• Potential for conflict(s) of interest:
– Not Applicable
Session Objectives
•
Assess the learning needs of the individual IMGs/CSAs
•
Identify IMGs/CSAs with early signs of difficulty requiring
preventative measures
•
Recognize IMGs/CSAs with complex difficulty requiring
remediation
•
Review past and current cases in your site/DFCM
4
Statistics
The organizations currently involve in coaching, integration, assessment,
evaluation and residency matching of International Medical Graduates are:
• 1- HealthForceOntario: involve in coaching, integration and career
advice
• 2- Centre for Evaluation of Health Professionals Educated Abroad
(CEHPEA): responsible for assessment, evaluation and Pre-Residency
Program (PRP)
• 3- Canadian Residency Matching System (CaRMS): central matching
system for residency programs in Canada
• 4- Ontario Family Medicine Program: a consortium of 6 Ontario’s
Family Medicine Residency programs (McMaster, Northern, Ottawa,
Queen’s, Toronto, Western) responsible for central selection of
International Medical Graduates into Family Medicine programs.
International Medical Graduates in Canada
A. Salman
International Medical Graduates in Canada
A. Salman
Competition for IMG Positions
Adapted from: CaRMS 2013
2500
2156
2000
1500
2216
1,920
1,486
1,299
1,387
1,497
1000
500
229
305
2007
2008
392
380
380
407
499
2009
2010
2011
2012
2013
0
Matched
Applicants
Number of applicants and matched positions for International Medical Graduates in Canada 2007-2013
8
NUMBER OF IMGS - 2010
With respect to the number of positions available in the first iteration of
the CaRMS Match, the University of Toronto-FM is one of the largest
IMG Programs in Canada
Discipline
UofT
ON
MB
BC
NS
Other
Total
Family
Medicine
24
(18.0%)
77
(57.9%)
18
(13.5%)
12
(9.0%)
6
(4.5%)
20
(15.0%)
133
Total
65
(23.7%)
166
(60.5%)
31
(11.3%)
18
(6.5%)
11
(4.0%)
48
(17.5%)
274
36.9%
46.3%
58.0%
66.6%
54.5%
41.6%
%
CaRMS 1st iteration , 2010
NUMBER OF IMGS - 2010
With respect to the number of positions in the first iteration of the CaRMS
Match, the University of Toronto-FM is one of the largest IMG Program in
Ontario
Discipline
UofT
Western
Ottawa
Queens
McMaster
NOSM
Total
Family Medicine
24
(31.1%)
19
(24.7%)
13
(16.9%)
11
(14.3%)
8
(10.4%)
2
(2.6%)
77
Total
65
(49.6%)
32
(24.4%)
30
(22.9%)
19
(14.5%)
24
(18.3%)
2
(1.5%)
131
36.9%
59.7%
43.3%
57.9%
33.3%
100%
%
CaRMS 1st iteration , 2010
IMGs and CSAs
• 2010 CARMS Canadian Students Studying Medicine
Abroad Report
• The term International Medical Graduate includes
physicians who immigrated to Canada after finishing their
MD (IMGs). It also includes Canadians who Studied
Abroad (CSAs). In the past 5 years, the number of CSAs
has increased significantly. CSAs also have been more
successful in securing a residency position than IMGs.
This report demonstrates the demographic of this
particular pool of applicants, the CSAs. Knowing these
demographics could assist faculty to prepare themselves
with a completely different sets of challenges than their
previous IMG cohorts.
Canadians Studied Abroad (CSAs)
Adapted from: CaRMS 2010 CSA Report
School
Adapted from: CaRMS 2010 CSA Report
Age
Adapted from: CaRMS 2010 CSA Report
Gender
Adapted from: CaRMS 2010 CSA Report
Marital Status
Adapted from: CaRMS 2010 CSA Report
Physician Parents
Adapted from: CaRMS 2010 CSA Report
Level of Education Before MD
Adapted from: CaRMS 2010 CSA Report
Application to Canadian Schools
Adapted from: CaRMS 2010 CSA Report
Motivation
Adapted from: CaRMS 2010 CSA Report
Year of Graduation
417
550
999
1142
424
321
Adapted from: CaRMS 2010 CSA Report
Median Debt
Adapted from: CaRMS 2010 CSA Report
Intention to Return
Adapted from: CaRMS 2010 CSA Report
Postgraduate Choice
Adapted from: CaRMS 2010 CSA Report
Specialty of Interest
Adapted from: CaRMS 2010 CSA Report
Perceived Barriers
Adapted from: CaRMS 2010 CSA Report
Early Detection
• Peer or Mentor support
• Reduced clinical workload
– Structured reading program
– Study group
– Time for increased practice and skill acquisition
•
•
•
•
Consideration for “Forward feeding”
Special courses/skills training
Learning assessment
Language/speech assessment
(Steinert, Nasmith and Tannenbaum)
27
M. Gottesman
SOAP
• Subjective: use experience and opinion to gain an
individualized impression of trainee
• Objective: Document specific examples of problem
• Assessment: Diagnose the problem
• Plan: develop and implement a plan to address the
problem
(Hicks, 2005)
28
Early Signs
•
Resident seems not able to grasp EMR or keep asking
same questions
Orientation
Computer literacy
Organizational skills
Analytical skills
29
Early Signs
•
Resident seems not able to schedule time or find his/her
way between point A and B
Orientation
Computer literacy
Organizational skills
Analytical skills
30
Early Signs
•
Resident does not transition smoothly between
clinics/services
Orientation
Anxiety
Culture
Common Sense
Professionalism
31
Early Signs
•
Resident Does not have enough knowledge or cannot
apply his/her knowledge
Rigidity
Following Check Lists
Approach/structure
Differential Diagnoses
Premature Closure
Complexity
Integration
Positive/Negative Pertinent
32
Early Signs
•
Resident seems not able to come up with a management
plan
Culture
Integration
Context
Common Sense
33
Early Signs
•
Resident seems not be patient-centric
Culture
Psychosocial
Determinant of Health
Community Services
34
Early Signs
•
Resident seems not be able to deal with gray area of
uncertainty
Culture
Anxiety
Training Style
Evidence-based
35
Early Signs
•
Resident seems not be motivated
Culture
Anxiety
Sense of Entitlement
Responsibility
Professionalism
distractions
36
Learners in Trouble
Learners in Trouble
• Prevalence 5.8-6.9%
• Requires +++ time and effort
• “Problem Learner”
– perform significantly below their potential doe to
specific difficulties
• “Problem Resident”
– demonstrates a significant enough problem that
requires intervention by someone of authority
(Hicks, 2005)
38
A. Monavvari
IMG Residents in Trouble
• Prevalence (anecdotal) 15-25%
• Risk factors for developing problems as a resident:
– Being older
– Part of an underrepresented minority
– IMGs
• Elements that disadvantage these groups:
–
–
–
–
Cultural difference
Language difficulties
Expectations
Previous experiences
(Hicks, 2005)
39
A. Monavvari
SUCCESS
• Dr. MacLellan’s study in Quebec looked at
IMGs and graduates of Canadian schools
who made it into residency programs from
2001 to 2008 and their results on the final,
certification exams to determine if they can
practice. The average pass rate for
international graduates was 56%, versus
93.5% for the Canadians.
SUCESS
• A separate study at Vancouver’s St. Paul’s
Hospital, where a special program was set up
for IMGs in 2006 to help them perform better,
found the internationals did as well as
Canadians on assessments during the
training, but that their final exam pass rate
was a “disappointing” 58%, compared to 97%
for the Canadians.
Learners Challenges
Rude
Easy To Manage
Hostile
Poor Integration Skills
Too Casual and informal
Over-eager
Avoids Work
Cannot focus on what is important
Does not Measure up Intellectually
Disorganized Disinterested
Avoids Patient Contact
A Poor Fund of Knowledge
Does not Show Up
Challenges Everything
All Thumbs
Frequent
Less Frequent
Cannot Be Trusted
Bright With Poor Interpersonal Skills
A Psychiatric Problem
Excessively Shy, Non-Assertive
A Substance Abuse Problem
“Con Artist” (Manipulative)
Hicks PJ, Cox S. et al Amer J Obstet 193 :2005
Difficult To Manage
A. Monavvari
Root Cause
Performance
WHY?
Below standard, anxious, in difficulty
WHY?
WHY?
WHY?
Analytical and interpersonal skills
Collaborator
Communicator
Organization
Manager
Integration
Time Management, Disorganized
Knowledge
Knowledge Base, Approach
Self-awareness
WHY?
Scholar
Insight, Common Sense
Confidence
Medical Expert
Health Advocate
Professional
Scholar
43
Interaction Between Challenges
Environment
Learner
Teacher
A. Monavvari
Guide
Challenge: Needs mild prevention from preceptor
and/or site remediation
Solution: Few suggestions
45
Environmental Challenges
• 1- Clinical Setting
– Orientation
– Objectives/Expectations
• 2- Workload
– Clinical Hours
– On Calls
– Complexity
• 3- Support
–
–
–
–
Program Director
Preceptor
Peers
Coaching/Mentorship
Case 1: Professionalism
• Resident arrives always late in your office
• Travel time between Hospital and clinic
• Does not drive
• Shy to tell other preceptor he/she needs to leave
early
• Other preceptor reviews all the cases at the end
of session
Case 1: Solution
• Schedule resident to minimize travel time
• Match resident/preceptor based on accessibility
• Discuss Professionalism/Travel time in your
orientation session
• Discuss with other preceptor to release resident
earlier
• Document clear expectations, objectives, tasks
and policies in residents handbook
Case 2: Professionalism
• Resident missed many academic half-days
• Expectations not clear from the program
Case 2: Solution
• Emphasize priorities during orientation session
• Meet with program director
• Ask to reflect
Case 3: Time Management
• Resident runs late everyday
• Multiple complex geriatric cases booked for
resident
• Too many calls/shifts this rotation
Case 3: Solution
• Book patients based on resident’s capability
• Book mix of complex and easy cases
• Accommodate resident when too many
calls/shifts
Case 4: Motivation
• Resident is not engaged/motivated
• Feels alone with no support
• New environment
• No friends
Case 4: Solution
• Create social support
• Regular meeting with program director and/or
chief resident
• Orientation session
• Buddy system
Teacher Challenges
1. Personal
– Mental Health
– Life Stressors
– Teaching Styles
2. Faculty Development
– Basic
– IMG-specific
3. Support
– Program Director
– Peers
– Coaching/Mentorship
55
Case 5: Confidence
• Resident lacking confidence
• Teacher wants to review all cases and changes
the plan all the time
• Teacher has no confidence in resident
• Teacher is anxious and control-freak
Case 5: Solution
• Discuss expectations upfront
• Use different preceptors
• Clear feedback
Learner Challenges
1. Personal
–
–
–
–
Mental Health
Physical Health
Family Stressors
Finance
2. Cultural
–
–
–
–
Learning styles
Self-direction
Feedback
Sensitive Issues
3. Communication
–
–
–
–
–
Verbal
Non-verbal
Interpersonal
Written
Presentation
4. Organization/Time Management
–
–
–
–
Info gathering
Prioritization
Analysis
Distractions
5. Attitude/Professionalism
–
–
–
–
Personal
Interpersonal
Safety
Risk
6. Knowledge
–
–
–
–
–
Basic
Clinical
Therapeutic
Discipline
Problem Solving
7. Skills
–
–
–
–
–
–
–
Interviewing
Physical exam
Problem Solving/Analysis
Patient-centered
Investigations
Management
Procedures
58
Case 6: Anxiety
• Resident seems very disorganized
• Worries about AVP
• Very anxious with no coping mechanism
• Talking about mental health issues is a taboo or
sign of weakness
• Worries about financial burden, send money to
family
Case 6: Solution
•
•
•
•
•
•
Life/Personal/Professional coach
Mentor
Resident well being
OMA Physician Health
Body system and peer support
Program director’s support
Case 7: Learning Culture
• Resident silent most of the times or constantly
agree and not offering any opinion
• Never should offer opinion
• Should back down immediately if challenged
• Verbalized criticism is highly threatening
Case 7: Solution
• Recognize difference to Authority
• Understand Hierarchical vs Constructive
learning
• Encourage resident to express his/her opinion
in a safe learning environment
• Probe resident
• Open communication to understand resident’s
position
• Set goals and objectives early in rotation
Case 8: Psychosocial
• Resident misses both verbal and nonverbal cues of
psychosocial distress or using highly technical
medical terms and appears uncaring
• Patient cues about homosexuality, marital
distress, substance abuse, premarital sex and
pregnancy are unfamiliar or too personal
• The use of alcohol as a coping mechanism may
be a foreign concept and viewed as sacrilegious
Case 8: Solution
• Train resident in cultural sensitivity and cultural
competence
• Focus interview on psychosocial aspect of
patient’s encounter
Case 9: Knowledge/Skills
• Never learnt these skills, or lost skills through
extended periods of absence from medical practice
• Female medical students only examine women and
children, whereas men seldom have the opportunity
to perform gynecologic
Case 8: Solution
• Personal one-to-one assessment of knowledge
and skills deficit
• Clinical case discussions
• Assignment of additional reading
• Extended time to complete assignments,
courses
• Tutoring
• Video-audio recording
• Consider learning disability assessment
Roles and Responsibilities
Detailed
Knowledge
Maximize resident’s
performance
Coach
(Faculty Advisor)
Referee
Cheerleader
(Teachers Committee)
(Supportive Faculty)
Team Manager
(Director)
Protect patients,
program and
discipline
Overall
Familiarity
A General Framework for Approaching Residents in Difficulty, C. Scott Smith et al., Residency Education, Vol 39, No , 1997
Importance of Cultural Awareness
Models of Teaching
Hierarchy
Feedback
Confidence
68
M. Gottesman
Models of Teaching
• Hierarchical Model of Teaching
– Teacher and content have all authority; not questioned
– Underlying assumption =
• ability does not vary among students, only effort
– (so why bother with self- assessment since we should all be the
same…)
• Constructivist Perspective on Teaching
– Students discover/create their own meaning of content
– Active engagement aids learning process
• Understanding content adds to students insight
(Pratt, 2005)
69
M. Gottesman
100
90
80
70
60
50
40
30
20
10
0
Phillipines
Mexico
Venezuala
India
Singapore
Brazil
Hong Kong
France
Colombia
Turkey
Belgium
Peru
Thailand
Chile
Portugal
Greece
Iran
Taiwan
Spain
Pakistan
Japan
Italy
Argentina
USA
Canada
Netherlands
Australia
Germany
UK
Switzerland
Finland
Norway
Sweden
Ireland
New Zealand
Denmark
Israel
Austria
Hierarchy: Power Distance Scores
(Hofstede, 1980 in Laroche, 2003)
70
Feedback in a Multicultural Context
(Laroche, 2005)
Poland (or- “I just don’t seem to be getting through!”)
Unacceptable Negative
Canada
Unacceptable Negative
0
Neutral
Positive
Excellent
0
Neutral
Positive
Excellent
Mexico or China (or – “They seem to read too much into it!”)
0
Unacceptable Negative Neutral
Positive
Excellent
71
M. Gottesman
The Issue of Confidence
• Learners have a desperate need to succeed
• Confusion: “supportive” training program ≈ assessor
– Asking for help can be unfamiliar
– Trusting the “safe learning environment” in Canada can be
unfamiliar
• Possible confidence-competence mismatch
– Overly confident learner:
• …may be internally not confident at all
• …may not know what they don’t know
– Under-confident learner:
• …may be too insecure to function independently
• …may not realize/be able to express what they know
72
M. Gottesman
Case 1: Deference to Authority
• Resident :
Never should offer opinion
Should back down immediately if challenged
Verbalized criticism is highly threatening
• Preceptor:
Trainee should support his/her decision
Silence interpreted as lack of knowledge, lack of interest or lack of
confidence
Constant agreement by a resident may be interpreted as
sycophantic
(Steinert Y, Walsh A (ed) 2006)
A. Monavvari
Case 2: Psychosocial/Culture
• Resident :
Patient cues about homosexuality, marital distress, substance
abuse, premarital sex and pregnancy are unfamiliar or too personal
The use of alcohol as a coping mechanism may be a foreign
concept and viewed as sacrilegious
• Preceptor :
Trainee missed both verbal and nonverbal cues of psychosocial
distress
Trainee using highly technical medical terms and appeared
uncaring
(Steinert Y, Walsh A (ed) 2006)
A. Monavvari
Case 3: Knowledge/Skills
• Resident :
Never learnt these skills, or lost skills through extended periods of
absence from medical practice
Female medical students only examine women and children,
whereas men seldom have the opportunity to perform gynecologic
• Preceptor :
Trainee displays uncooperative behaviors or attitudes
May be perceived as disinterested or a poor team player, or may
just not be able to cope
(Steinert Y, Walsh A (ed) 2006)
A. Monavvari
Case 4: Communication
• Resident :
No non-technical terms for medical problems
Lack of specific vocabulary
Unfamiliar with certain terms and phrases
Unaware of nonverbal communication
Don’t know how to negotiate treatment plans with patients, break
“bad news” and discuss end-of-life issues with patients and
families.
• Preceptor :
Trainee’s don’t speak, it is because he/she don’t know or don’t
care
(Steinert Y, Walsh A (ed) 2006)
A. Monavvari
Case 5: Motivation/Fatigue
• Resident :
In early 40s with two young children, arrived as refugee with no
extended family
Financial stress, exhaustion, several years of intense anxiety, loss
of self-esteem, loss of country, loss of accessibility to a natural
network of support, and loss of lifestyle
Unable to ask for help because of cultural taboos and cultural
requirement for stoicism
• Preceptor :
Trainee’s anxiety and depression interpreted as lack of knowledge,
diffidence about the program or arrogance
(Steinert Y, Walsh A (ed) 2006)
A. Monavvari
Case 6: Feedback
• Resident :
Should know everything therefore saying “Don’t know” perceived as
weakness
More familiar with indirect feedback, and when direct feedback is
given, this may be interpreted as “criticism and disappointment,
leading to anxiety, loss of self-esteem and decreasing performance”.
Feels unsecure due to fear of failure
• Preceptor :
Trainee is not receptive to feedback or becomes very defensive
Lack of self-evaluation and self-directed learning
(Steinert Y, Walsh A (ed) 2006)
A. Monavvari
References
•
Bates J and Andrews R. Untangling the Roots of Some IMG’s Poor
Academic Performance. Acad Med 2001;76:43
•
Carlisle C. Reflecting on levels of confidence and competence in skills
acquisition. Med Ed 2000; 34:886
•
Laroche LF. 2003. Managing Cultural Diversity in Technical Professions.
Woburn, MA: Butterworth-Heinemann
•
Hicks PJ et al. TO the Point: Medical Education reviews- Dealing with
student difficulties in the clinical setting. Am J ObGyn 2005; 193:1915-22
•
Pratt, D. “Cross Cultural Differences in Teaching and Learning: Looking
through the eyes of our students”. Faculty of Medicine Rounds, University
of Toronto, April 2005.
•
Searight HR and Gafford J. Behavioural Science Education and the
International Medical Graduate. Acad Med. 2006;81:164-70.
•
Stewart J, O’Halloran C, Barton JR, Singleotn SJ, Harringan P, Spencer J.
Clarifying the concepts of confidence and competence to produce
79
appropriate self-evaluation measurement scales. Med Ed 2000;34:93
References
•
Canadian Students Studying Medicine Abroad, CaRMS report, 2010
80