International Medical Graduates From Prevention to Remediation Alan

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 - Health. Force. Ontario: 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 (Ca. RMS): central matching system for residency programs in Canada • 4 - Ontario Family Medicine Program: a consortium of 6 Ontario’s Family Medicine Residency programs (Mc. Master, 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: Ca. RMS 2013 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 Ca. RMS Match, the University of Toronto-FM is one of the largest IMG Programs in Canada Discipline Uof. T 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% % Ca. RMS 1 st iteration , 2010

NUMBER OF IMGS - 2010 With respect to the number of positions in the first iteration of the Ca. RMS Match, the University of Toronto-FM is one of the largest IMG Program in Ontario Discipline Uof. T Western Ottawa Queens Mc. Master 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% % Ca. RMS 1 st 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: Ca. RMS 2010 CSA Report

School Adapted from: Ca. RMS 2010 CSA Report

Age Adapted from: Ca. RMS 2010 CSA Report

Gender Adapted from: Ca. RMS 2010 CSA Report

Marital Status Adapted from: Ca. RMS 2010 CSA Report

Physician Parents Adapted from: Ca. RMS 2010 CSA Report

Level of Education Before MD Adapted from: Ca. RMS 2010 CSA Report

Application to Canadian Schools Adapted from: Ca. RMS 2010 CSA Report

Motivation Adapted from: Ca. RMS 2010 CSA Report

Year of Graduation 417 550 999 1142 424 321 Adapted from: Ca. RMS 2010 CSA Report

Median Debt Adapted from: Ca. RMS 2010 CSA Report

Intention to Return Adapted from: Ca. RMS 2010 CSA Report

Postgraduate Choice Adapted from: Ca. RMS 2010 CSA Report

Specialty of Interest Adapted from: Ca. RMS 2010 CSA Report

Perceived Barriers Adapted from: Ca. RMS 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: ubjective use experience and opinion to gain an individualized impression of trainee • Objective: bjective Document specific examples of problem • Assessment: ssessment Diagnose the problem • Plan: lan 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. Mac. Lellan’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? Scholar Analytical and interpersonal skills Collaborator Communicator Organization Manager Integration Time Management, Disorganized Knowledge Base, Approach Self-awareness Insight, Common Sense Confidence Medical Expert Health Advocate Professional Scholar 43

Interaction Between Challenges Environment Learner Teacher A. Monavvari

Guide Challenge: hallenge Needs mild prevention from preceptor and/or site remediation Solution: olution 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 Ø Models of Teaching Ø Hierarchy Ø Feedback Ø 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

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!”) 0 Unacceptable Negative Canada Unacceptable Neutral Positive Excellent 0 Negative 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 40 s 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 Ob. Gyn 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, Ca. RMS report, 2010 80