Untangling the Roots of Some IMGsʼ Poor Academic Performance

Abstract

International medical graduates (IMGs) make up 18% of postgraduate medical trainees in the United States1 and approximately 20% in Canada.2 The majority of these IMGs are training in primary care specialties such as family medicine, pediatrics, and general internal medicine.3 Overall, IMGs are less successful on national licensing examinations, than are graduates of North American medical schools.4–6 There is also evidence that some of these trainees do less well during their postgraduate training and require more remediation.7 As a result, postgraduate program directors may be reluctant to consider IMG applicants to their programs because of perceived difficulties in training these physicians.8 IMGs themselves have written movingly about the difficulties they face entering medical practice in North America,3 and faculty have written about the difficulties facing IMGs in training.9 While many IMGs successfully complete residency training with few serious problems, the problems some do encounter may be difficult to remediate without a deeper understanding of the underlying issues specific to IMGs. Between 1994 and 2000, the University of British Columbia (UBC) Family Practice Residency program trained 18 IMGs in a community-based family medicine program associated with St. Paul's Hospital, an inner-city, tertiary care teaching hospital in Vancouver. They were part of a cohort of 72 family practice residents who trained at this site during that time. The IMGs accessed the family medicine training primarily through a government-paid program for licensure.10 These IMGs were carefully selected to minimize training difficulties, and final outcomes were excellent in that all graduates were licensed and are practicing in the community, many providing medical care to the ethnic groups to which they themselves belong. However, both the family practice faculty and the IMG residents experienced problems in the course of training that required careful exploration and new responses. Problems presented as academic, attitudinal, or behavioral issues and the difficulties encountered were complicated by differences in the structure of medical training in the IMGs' countries of origin, cultural differences, language difficulties, and the different life stages and stresses of the IMG residents. The family medicine program at UBC is a community-based residency, eight months of family medicine training taking place in community family practices, eight months in hospital-based rotations, and the remainder of the time allotted to elective experiences. In the family medicine rotations, at any sign of academic difficulty, a faculty member with experience in direct observation and evaluation is called in to participate with the preceptor and site director in delineating the problem and recommending interventions. These problems were logged and tracked and the descriptions below arise from our experiences with IMG residents in the two-year program. Some of the scenarios have been altered to protect the anonymity of the residents involved, although the content is derived from actual experiences. SITUATION A A resident who initially had appeared to have solid knowledge and clinical skills was unable to make a decision in a clinical setting. Her performance continued to deteriorate in spite of careful formative feedback. Explanation The resident came from a training system in which the attending physicians made all the decisions. She had been trained never to offer an opinion to a senior physician and, if asked to do so, to back down immediately rather than support her diagnosis if challenged. Feedback exacerbated the situation, as verbalized criticism was not part of the resident's culture and was perceived as highly threatening. The resident felt she was failing and expected to be terminated from the program immediately. Discussion The usual style of North American medical education is a Socratic method in which trainees attempt to support their decisions to their supervising physicians and defend their actions. However, many IMGs come from cultures and training programs where deference to authority is the norm and questioning a professor's opinion is unthinkable. Unfortunately, in North America, the IMG's silence may be interpreted as lack of knowledge, lack of interest, or lack of confidence. A resident's constant agreement with the more senior physicians on rounds may be perceived by other residents as sycophantic and could widen the gap between the IMG and North American-trained graduates. In many cultures, criticism is never offered directly, and IMGs can react very differently from North America-trained residents to the ways in which we in North American offer both positive and negative feedback. Negative feedback may be perceived by an IMG as personal criticism, be interpreted as failure, and significantly decrease self-esteem. Delivering appropriate feedback becomes a very delicate matter, and the perception of the IMG needs to be carefully explored. The differences in training systems and expectations were clearly articulated to this resident and the interaction between the resident and preceptor were restructured to account for the cultural deference to authority. With more careful feedback techniques, the resident quickly regained confidence and started to perform appropriately in the clinical setting. SITUATION B A resident who had performed well in his first year experienced difficulty in a senior family medicine rotation in a community clinic, where most patients were from a lower socioeconomic group. His preceptor complained that he missed both verbal and nonverbal cues of psychosocial distress, spoke to patients using highly technical medical terms, and appeared uncaring. Explanation The resident, who had learned excellent medical and social English in a short time, had virtually no nontechnical terms for medical problems in his vocabulary. For example, he was unable to find a nontechnical way of expressing “urinary tract infection.” This lack of specific vocabulary was masked by his excellent social and medical English. Furthermore, the resident came from a country in which any deviation from the dominant culture was never acknowledged. Cues or explicit information about homosexuality, marital distress, and substance abuse were all carefully (and appropriately, for this resident within his own culture) ignored. The resident's generally authoritative stance was appropriate to the exceptations of patients in his own country, but his North American preceptor perceived him to have a negative attitude toward the marginalized patient population. Discussion For most IMGs, English is a second language. They may have learned colloquial English through their family interactions, but have little experience with medical English, having received their medical instruction in another language. Alternatively, they may have learned excellent medical English, but, because much of their daily conversation had been in their native tongue until they were admitted into postgraduate training, they may be unable to coverse in colloquial English. Both of these language difficulties pose potential problems for IMGs in a residency program. Additionally, many IMGs may speak with accents that create barriers to understanding between themselves and their patients, and that may also create difficulty in group instructional interactions. Eventually, there is a tendency for the doctor-patient relationship to break down, for the resident to be ignored or to become increasingly reluctant to speak. Patients from other countries may expect a more authoritarian attitude from their physicians than do patients from North America. Further, IMGs may perceive male/female gender roles differently than do their North American counterparts. A lack of exposure to patients of the opposite sex during medical school, and previous training in professional attitudes appropriate elsewhere (e.g., authoritarianism) may leave the IMG trainee uncertain of how to be-have toward North American patients or colleagues. Once the language difficulty was identified, the preceptor in the above situation carefully increased the resident's vocabulary by having him practice with the preceptor, what he was going to say to the patient to increase his non-technical medical vocabulary. He was intensively instructed in exploring cues of psychosocial distress, which he had no difficulty learning. As his vocabulary and exploration of psychosocial issues improved, he was able to modify his authoritarian stance. SITUATION C A resident who had demonstrated excellent knowledge and skills in other rotations failed a rotation in pediatrics. He was evaluated as having behavioral and attitudinal issues, with lack of participation and poor team behavior as he interacted in an abrupt, curt, and aggressive manner with senior residents. Explanation This resident had completed his MD degree in a program in which students were streamed in the first year toward adult or pediatric medicine. He, in fact, had virtually no clinical experience in pediatrics, and his content knowledge was minimal. Because of his experiences as a persecuted minority and a refugee claimant, he was highly suspicious of authority, and was unable to admit this lack of knowledge. He had been culturally trained to respond to his own distress with aggression, disrupting the medical care team. Discussion While medical school teaching in North America is standardized by the Liaison Committee of Medical Education, undergraduate medical training may differ greatly around the world. Emphasis may be placed on aspects of training quite different from the North American norm. What is considered “core medical education” differs and IMGs may have excessive training in one area and a deficiency in another in comparison with North American students. Some trainees appear to have much higher levels of content knowledge in such areas as anatomy, but weaknesses in pathophysiology or doctor-patient communication. In some countries, female medical students may have examined only women and children, and men may seldom have had the opportunity to perform gynecologic examinations. Many IMGs may have completed their medical education many years before they arrived in the United States or Canada, and their knowledge in areas outside their clinical practice experience may not have been kept up to date. Conversely, IMGs may have superior skills in some areas because of extensive clinical experience. IMGs' performance may vary depending on the clinical context, and program faculty should make an effort to learn about IMGs' experiences in medical school and since graduation and offer remediation as needed. This resident' experience was restructured to provide an intense experience in pediatrics to increase both his academic core knowledge and his clinical experience. The remediation time was taken out of internal medicine, where the resident had well-above-average knowledge and skills for his level of training in the North American system. When culturally based differences in communication styles were clearly articulated to the resident, he quickly modified his behavior and completed the program successfully and on time. SITUATION D The performance of a very competent IMG resident deteriorated in her second year. She appeared disinterested and completed a minimum of work. Faculty were concerned that she was “marking time” to achieving her licensure status. Explanation This resident was in her early 40s and had two young children. She and her husband had arrived as refugees and had no extended family in Canada. Financial stress, exhaustion, and several years of intense anxiety were taking their toll. The resident had been unable to ask for help because of cultural taboos and a cultural requirement for stoicism. Discussion Most IMGs are older than the usual residents and may have increased family and financial responsibilities. Differences in age and life stage may contribute to the gap between IMGs and domestically trained graduates in residency programs, and many IMGs do not have the links with classmates and friendships that bind most groups of residents. Although many have rich cultural communities to fall back on, most are without extended family at hand who can ease the responsibility of child care and other responsibilities during residency. For the IMG, starting a residency is a time of increased responsibility, higher expectations, and a sharply focused realization that he or she is now being accepted into the medical community. However, there is often the sense that they must prove themselves. These residents' anxiet and depression can be interpreted as lack of knowledge, diffidence about the program, or arrogance. Admission of anxiety, stress, or depression may be culturally taboo in IMG's home culture. In this situation, faculty realized that this resident was exhausted and depressed. She was gently encouraged to take a leave of absence and seek medical treatment. This was made more acceptable to her by being structured as a leave to prepare for upcoming examinations. She completed the program successfully, passing all examinations. CONCLUSION Some of the performance difficulties that may be experienced by IMGs in a residency may be similar to those of graduates trained in North America. However, the underlying problems that lead to performance difficulty may be very different for the two groups. IMGs' circumstances are unique and may include the following: ▪ Difficulty with English (either medical and/or nonmedical) ▪ Differences in medical education ▪ Length of time since graduation from medical school, and length of time since last clinical experience ▪ Difference life stages with attendant family and financial obligations ▪ Traumatic experiences as persecuted minorities, refugees, or new immigrants ▪ Cultural differences in approaches to and beliefs about communication, authority, gender roles, interpersonal relationships, and the role or status of physicians Unless faculty and administrators fully explore the circumstances leading to performance difficulties of IMGs, any remediation they devise may be inappropriate, and may in fact lead to eventual frustration and failure. Ensuring that IMG residents have opportunities to describe and explore their own undergraduate training and the cultural expectations of physicians in their countries of origin will not only increase faculty understanding of the backgrounds of these trainees, but also enrich the experiences of other graduates in the residency program. However, training IMGs effectively in primary care residency programs requires a clearly articulated approach that includes the following: ▪ Exploration of the trainees' undergraduate experiences, postgraduate experiences, and clinical activities ▪ Exploration of the trainees' personal circumstances ▪ Exploration of the trainees' expectations of medical education, as well as their relationships with nurses and other paramedical personnel and with medical students and faculty ▪ Exploration of the doctor-patient relationship in the trainees' countries of origin ▪ Clear articulation of the program's expectations for participation, feedback, work ethic, and commitment ▪ Clear articulation of North American society's expectations of physicians ▪ Experienced faculty with the resources and the interest to explore the roots of academic difficulty The inclusion of IMGs into postgraduate training can, through spirited dialog, enhance the cultural basis of clinical practice in North America, as well as the requirements of delivering culturally appropriate care to patients of differing ethnic origins. The difficulties sometimes experienced in the training of IMGs can shift postgraduate programs to a more learner-centered approach, where the roots of learning (and the difficulties of performance) are explored in the context of the learner.