International medical graduates (IMGs) needs assessment study: comparison between current IMG trainees and program directors

Several studies note that International Medical Graduates (IMGs) experience additional problems relative to their Canadian counterparts such as loneliness, social isolation, concerns related to family members left behind in home countries, a decrease in social status with an accompanying diminishment of self-esteem, lack of financial resources and worries about visas/immigration issues [1, 3]. Although some demographic commonalities exist among IMGs (such as generally being older, previously trained and/or practicing, and responsible for supporting a family), heterogeneity is also found due to variations in their life stages and perceptions of health and health care [4, 5]. Furthermore, the level of medical training they have received prior to entering residency varies, which may prove challenging to supervisors. To address the difficulties IMGs face, previous studies find that exposure to an orientation program prior to entering postgraduate training is beneficial [6].

However, most orientation programs tend to concentrate on a specific skill, namely communication or cultural-sensitivity training. In a pilot study conducted at one Canadian medical school, IMGs participated in an 18-hour communication program, focusing on doctor-patient and doctor-colleague interaction during the first year of residency. Although the sample size was small, self-evaluations scores showed significant improvement after these sessions [7]. In another study, IMGs in one residency program were divided into two experimental groups to measure Emotional Resilience, Flexibility, Perceptual Acuity and Personal Autonomy. After cultural-sensitivity training, the experimental group (Group A) scored significantly higher in flexibility, emotional resilience and perceptual acuity than the control group. These IMGs were more self-confident, willing to learn from others, and able to correctly assess verbal and non-verbal cues [3].

In light of this, a needs assessment study was conducted at the University of Toronto to explore the extent that these specific issues were challenging for IMGs in a residency program from the perspective of Program Directors and foreign-trained physicians themselves.

Among the IMGs surveyed, Knowledge of the Canadian Health Care System received the highest mean score, followed by Knowledge of Pharmaceuticals and Hospital formularies (3.69), and Knowledge of Hospital Systems (3.69). The lowest mean rating scores were Basic Clinical Skills (2.78), Working Relations with Other Residents (3.05) and Working Relations with Other Healthcare Students and Allied Healthcare Professionals (3.13).

In contrast, the three highest mean scores among Program Directors were Communication with Patients (4.40), Communication with Team Members (4.33) and Basic Clinical Skills (4.28). The lowest mean scores were Knowledge of Hospital Systems (3.19), Specialty-specific Clinical Knowledge (3.37), and Specialty-specific Clinical Skills (3.46). Mean scores for Program Directors were higher relative to IMG trainees for all challenges presented in two categories: Knowledge and Skills and Communication and Working Relations. Mean scores for all Macro Issues were lower among Program Directors relative to the mean scores of IMGs.

Approximately three-quarters of all participants agreed that an orientation program specifically targeted for IMGs is needed. When broken down by group, 93% of all Program Directors surveyed believed that an orientation program was necessary. A smaller majority (63%) of IMGs believed such a program would be beneficial.

Among the IMGs and Program Directors surveyed at our medical school, the majority agreed that an orientation program for all IMGs is required before starting a residency program. Such a program is currently provided for IMGs in the Faculty of Medicine and is reported to be insufficient (Childs and Herbert, Assessing IMG Performance at Ontario Medical Schools 2002–06 Final Report, December 2007). This finding is supported by previous work conducted in the United States. Mylonakis, Mega, and Schiffman [8] found that 37% of US Internal Medicine Program Directors agreed that a pre-residency training program should be mandatory prior to IMGs entering training. Other studies by Levey [9], Kidd and Zulman [10] and Kramer [1] found similar results.

Mean scores for Basic Clinical Skills differed between IMGs and Program Directors and may be related to the variability of training IMGs possess prior to entering the Canadian medical education system. With regards to Communication and Working Relations, mean scores were relatively higher among Program Directors, which may indicate they are more concerned with the communication skills and interprofessionalism of IMGs, in comparison to IMGs themselves. This is consistent with previous literature [11, 7].

These findings are not exclusive to foreign-trained physicians. Yahes and Dunn [12] found that the biggest challenge experienced by foreign-trained nurses was a lack of communication skills. After completing two-hour sessions over the course of 12 weeks (dealing with group interaction, non-verbal cues, pronunciation and voice intonation) subjects reported a higher rate of job satisfaction and collegiality. Nursing administrators also noted a decrease in the number of complaints from physicians and staff with regards to communicating with these foreign-trained nurses.

All three Macro-level Issues (Knowledge of the Canadian Health Care System, Knowledge of Pharmaceutical and Hospital Formularies and Knowledge of Toronto Hospital Systems) received the highest mean scores among IMGs. System issues may prove especially challenging to IMGs who are required to learn the values of a new country's healthcare system and the culture of a hospital and its numerous administrative protocols, in addition to their medical curriculum. Program Directors may feel such issues are not challenges or may only view these as pertinent once the trainee begins his/her residency.

These concurrent surveys of IMG residents and their Program Directors at the University of Toronto illustrated that both cohorts feel that IMGs need better integration into their residency programs. Interestingly, the groups differed in the areas of concern with residents acknowledging their anxiety about a lack of knowledge and comfort in many macro areas, namely institutional and societal transition areas, whereas Program Directors were more concerned with areas of performance indicators in communication, collaboration and basic clinical skills. Each group responded based on their needs and anxieties, possibly indicating that they need to be educated about each other's perspectives.

IMGs are forming a major part of our training cohort, thus representing an increasing number of physicians entering into practice as a short-term solution to health human resource needs. A proliferation of IMG entries has not been accompanied by robust strategies to optimize their integration and bridge their transition into residency. In this study, IMGs have identified specific challenges as have their Program Directors. A comprehensive and integrated program is needed to facilitate the success of IMGs.