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.
Limitations
The project was designed as a needs assessment study to explore the extent to which specific issues were challenging to IMGs from the perspective of IMG trainees and Program Directors. As it stands, the survey instrument has only face validity.
Secondly, this study is exploratory in nature. As the survey only provided pre-selected issues, participants were restricted in ranking the choices presented. Follow-up studies using focus groups with IMGs may help to expand on their experiences or uncover specifics that cannot be captured using close-ended questions. The same qualitative methods should be used to explore the perceptions of Program Directors, not only for contrast, but also to identify other issues that may not be shared by the IMG cohort.
Conclusions of this study are specific to the perceptions of IMGs and Program Directors of medical residency programs at the Faculty of Medicine at the University of Toronto. It cannot be concluded that IMGs and Program Directors at other Canadian medical schools or elsewhere perceive these issues as challenges, or to the same extent as those who participated in this study.