ORIENTING TEACHERS AND IMGs Part A Orienting Teachers

ORIENTING TEACHERS AND IMGs Part A: Orienting Teachers – Understanding the IMGs’ World Part B: Orienting IMGs – Understanding the Canadian Health Care System and Learning Environment A Faculty Development Program for Teachers of International Medical Graduates

Module Rationale: Part A ● ● Focus is on developing an understanding of the IMG as a learner and as a physician The goal is to facilitate the development of a supportive learning environment and learnercentered strategies

Objectives - Part A ● ● ● Describe the experience of IMGs, including the immigrant experience in general as well as experiences specific to the medical role Outline the strengths, common areas of challenge and typical cultural and attitudinal issues that faculty report when teaching IMGs Discuss the Canadian cultural lens, examining the assumptions, values and beliefs faculty hold about IMG learners Identify strategies to orient a faculty member to an individual IMG Create a foundation for building a learner-centered approach to teaching IMGs

PART A: ORIENTING TEACHERS – Understanding the IMGs’ World Information and resources that orient teachers to the challenges faced by international medical graduates

Principles ● ● The background of individual IMGs is very diverse Each IMG will have different strengths and gaps, requiring an individualized approach The teaching strategies are not significantly different from those used with Canadian-trained learners However, the focus and emphasis may be different

Who is an International Medical Graduate? 1. Canadian IMGs: – Canadian citizens who have completed their medical training outside of Canada or the USA 2. Visa IMGs: Foreign-trained medical graduates, working in under-serviced areas. They hold working visas and function as physicians. Many of these physicians are from the United Kingdom, New Zealand, Australia or South Africa – Foreign-trained medical graduates who are sponsored (often by their governments) to train in specific medical schools or postgraduate training programs with the expectation that they will return to their sponsoring countries – 3. Immigrant IMGs: – Immigrants to Canada who hold recognized medical degrees § Accessing training through IMG-specific programs § Accessing training through the Ca. RMS second iteration match

Understanding the IMG Experience The immigrant experience: ● Loss Professional – Extended Family – Culture – ● ● ● Prejudice Trauma Language

Understanding the IMG Experience – Loss "Medicine has been my whole life until I came here. And it's very hard to give up, it's almost addictive. ” "You know, it sounds very simple …I had always wanted to be a doctor. " "I guess it's the passion for practicing medicine which is driving me on. " IMG Voices

Understanding the IMG Experience – Loss ● Profession ● Extended family ● Culture

Understanding the IMG Experience – Trauma “An IMG trainee has already gone through many life-altering, even tragic, experiences and has overcome hurdles just to get into residency. They are likely exhausted, financially stressed, scared anxious. ” Kvern, 2001

Understanding the IMG Experience Prejudice “Feelings of discrimination also contribute to the challenges for IMGs who might feel that they have been discriminated against with respect to race, educational background, religion, country of origin and appearance. ” Sannoufi, 2004

Understanding the IMG Experience Language IMGs face three (3) potential issues when approaching language competency: ● Medical training may have been in another language, and therefore, their knowledge of medical English may be limited ● Medical training may have been in English resulting in good medical English but little colloquial English ● A significant accent may impair interactions with both patients and preceptors even if both medical and colloquial English is adequate Bates & Andrew, 2001

Understanding the IMG Experience Language “When you have to think of every word you say, it is very difficult. ” Sannoufi, 2004

IMG Narratives – The Immigrant Experience ● ● ● How does this information impact on your view of IMGs? How would you feel if you had to stop practicing medicine or had to take a prolonged absence from medical practice? Will this information affect how you approach teaching IMGs?

Understanding the IMG Experience – Obstacles to Medical Practice: ● The immigration process ● Access to the medical profession

Obstacles to Medical Practice The immigration process: ● ● ● "It was devastating for me. . . the interview at the Embassy when I was told I would never, ever be able to practice medicine. " "On our immigration papers, I was not allowed to put in doctor as my profession. The lawyer who processed our papers said that if you put your profession as a doctor, you wouldn't be allowed to immigrate so I came in as a homemaker. " "I was under the impression that it was going to be difficult to get a job but I didn't think it was going to be impossible. " IMG voices

Obstacles to Medical Practice Access to the medical profession: ● DIRECT COSTS ● INDIRECT COSTS

Direct Costs • Medical Council of Canada Evaluating Exam - (costs: $200 for credential review & $800 exam fee) • Medical Council of Canada Qualifying Exam Part l - (cost $680) • TOEFL - (cost $150) • Application fees to provincial IMG recruiting programs • Translation of documents • Credential verification – Provincial Colleges of Physicians & Surgeons • Ca. RMS – (cost $240 + tax plus $75 credential verification)

Results ● ● Many IMGs who pass all these hurdles are still unable to practice medicine. 16% of Ca. RMS applicants (500 -600 registered) were successful in finding residency positions. Crutcher, Banner, Szafran, & Watanabe, 2003

Indirect Costs ● Income generation ● ‘Observerships’ ● References

Discussion Questions ● ● What has your experience been with IMGs? What are your thoughts about the integration of IMGs into the Canadian health care environment? What advantages do you anticipate from this integration? What worries do you have about teaching IMGs?

What Concerns Prevent the Integration of IMGs? ● The cultural lens ● Maintenance of Canadian standards ● Clinical skills

The Cultural Lens “It is impossible to adequately conceptualize or effectively work with learners from other cultural backgrounds without first challenging ones’ assumptions, beliefs and values about who the learners are. ” Guy, 1999

Maintenance of Canadian Standards ● Insufficient medical school places ● Stringent accreditation requirements ● 21% of IMGs pass certifying exams compared to 95% of Canadian graduates

Strengths and Common Areas of Remediation

Strengths ● From your clinical experience, what strengths have IMGs displayed?

Strengths ● ● ● Often training in other disciplines Often have seen diseases and disease processes with which Canadian physicians have little or no familiarity Dependence on clinical skills because of limited access to diagnostic tests and investigations Often older and have more diverse life experiences Provide a window into their respective cultures, which may be advantageous when caring for patients of the same culture Other strengths?

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Common Areas of Remediation or Challenge ● From your experience, what are some areas you have needed to address with IMG learners?

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Eleven Common Areas of Remediation or Challenge ● ● ● Previous training - often didactic, large group, content focused Time lag since training or practice - may impact currency & accuracy of knowledge Familiarity with family medicine Resource use - access, judicious use, cost Learning & teaching roles and expectations - hierarchical settings with no learning risks & no exploration of clinical reasoning Clinical experience - minimal patient contact or contact limited by gender, age & race of either the patient or the physician

Eleven Common Areas of Remediation or Challenge (Cont’d) ● ● ● Clinical gaps - urogenital & rectal exams, obstetrical care, adolescent medicine, psychiatry, intensive care, geriatrics Psychosocial issues - psychiatric illness, family violence, abortion, rape, drug/alcohol abuse, gender roles and identities Doctor-patient relationship - paternalistic training with little experience in communication skills, or patient education Interprofessional relationships - may not have worked with many members of health care team; may have limited experience with well-trained nurses/pharmacists Evidence-based medicine

Discussion of Challenges in Teaching IMGs ● ● ● Divide into smaller groups of 3 or 4 teachers Designate one person as the timekeeper and one as reporter Choose a particular teaching issue (from group experience) Discuss the teaching challenges and potential solutions associated with this issue The reporter should capture both challenges and solutions On return to the large group, the reporter will present the top three challenges and solutions from the small groups to the large group

IMG Narrative ● ● What issues do you see identified within the narrative that feel consistent with your experience? What are possible approaches & solutions to address these concerns?

Video Clips ● ● What would your learning plan include for this learner? What might you chose to do differently, as a teacher, given the IMG’s previous learning environment? What strategies would you use to address the cultural components of learning? How would you encourage questioning?

Orientation to the Individual IMG ● Assessment of previous learning experiences ● Use of portfolios ● Narratives

Orientation to the Individual IMG ● Preceptor Interview Guide ● Portfolios “Portfolios include documentation of learning and an articulation of what has been learned…. It is essential that the portfolio does not become a mere collection of events seen or experienced, but contains critical reflections on these and the learning that has been made from them. ” Snadden & Thomas, 1998 ● Narratives

Orientation to the Individual IMG (Cont’d) ● ● Workplace expectations, rules & responsibilities Components of the medical interview, physical exam, procedures ● Process for evaluation & feedback ● Learning contracts ● Log sheet of student questions ● Critical appraisal & literature search skills ● Modeling & critical reflection

Ongoing Faculty Development & Support ● Peer coaching ● Videotape review of teaching interactions ● Use of reflective learning journals ● Small group discussions

PART B: ORIENTING IMGs. Understanding the Canadian Health Care System and Learning Environment Information and resources that provide teachers with information needed to orient IMGs to the Canadian health care system

Objectives - Part B ● ● Provide an overview of the Canadian health care system, the role of the physician within this system, the patientcentered approach and the team-based practice environment Present a model that will highlight the typical Canadian learning setting and examine some potential differences between this environment and the IMGs’ previous experience Describe the role of self-directed learning, problem solving and feedback Identify interpersonal competencies including patientcentered interviewing, socio-cultural training and ethics

Orientation to the Canadian Health Care System ● The components of the health care system and how they are delivered. – National health care system (http: //www. img-canada. ca) § § Organization and Development of Health Care in Canada Roles of Federal and Provincial/Territorial Governments Professional Organizations Non-Governmental Organizations

Orientation to the Canadian Health Care System ● The components of the health care system & how they are delivered – How is the health care system organized within the particular province or health region? § The role of regional health boards or other organizational bodies. Examine the structure of the organizations, their links to physicians and their role in health care decisionmaking § Hospitals, nursing homes, office practice, other resources. How is health care typically delivered in the setting in which the IMG will be working? Who works in each of these venues and what are their roles and responsibilities?

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Orientation to the Canadian Health Care System ● The team-based approach to care delivery ● The role of the physician within the system ● The delivery of patient-centered care

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Orientation to Learning ● ● Common learning differences & challenges reported by IMGs & their teachers The Canadian learning environment Components of an effective learning environment Tips & traps

IMGs’ Previous Learning Environment ● Hierarchical structure ● Lecture-based format ● ● ● Surface approach to learning Process of clinical reasoning Patient presentation format Minimal contact with patients, or limited by age and gender Acknowledgment of knowledge or skill deficits Deference to teachers

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The Canadian Learning Environment

A General Model of Teaching Context Learners X Content Ideals Y Z Teacher Pratt, 1998

Transmission Perspective Context Learners Content Ideals Z Teacher Pratt, 1998

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Apprenticeship Perspective Context Learners Content Ideals Teacher Pratt, 1998

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Developmental Perspective Context Learners X Content Ideals Teacher Pratt, 1998

Nurturing Perspective Context Learners Content Ideals Y Teacher Pratt, 1998

The “Bottom Line” ● ● The learning environment may be more supportive and encouraging than many IMGs are accustomed to Learners are expected to take much more control of their learning Teachers will be supportive and act as facilitators Teachers will often be focused on uncovering and enhancing thinking processes rather than presenting content. Through discussing their knowledge, and uncovering their clinical reasoning, the teacher acts to bridge their knowledge and skills to higher levels

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The Canadian Learning Environment Better Practice Interpersonal competencies: • Communication skills • Ethics • Professionalism • Socio-cultural issues Self-directed learning Learning opportunity Identify the gap: • Knowledge • Skills • Attitudes Teacher questioning Feedback Learning contracts Expectations Current Practice

The Canadian Learning Environment Better Practice Interpersonal competencies: • Communication skills • Ethics • Professionalism • Socio-cultural issues Self-directed learning Learning opportunity Identify the gap: • Knowledge • Skills • Attitudes Teacher questioning Feedback Learning contracts Expectations Current Practice

Expectations ● ● IMGs report some consistent areas where the expectations of teachers are tacit and based on common training and culture IMGs report that exposure to Canadian residents is a significant factor in orienting them to residency expectation – Organizing an opportunity during orientation for residents to interact with regular stream residents and other IMG residents will be helpful – An alternative would be an opportunity for IMGs to shadow another resident (especially in the inpatient setting)

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The Canadian Learning Environment Better Practice Interpersonal competencies: • Communication skills • Ethics • Professionalism • Socio-cultural issues Self-directed learning Learning opportunity Identify the gap: • Knowledge • Skills • Attitudes Teacher questioning Feedback Learning contracts Expectations Current Practice

Learning Contracts ● Important way to focus self-directed learning ● Develop a learning contract for each rotation ● ● Take time at the start of each rotation to discuss the tasks and responsibilities of that rotation Discuss how feedback will be given Commit to a learning task and follow through Review new knowledge, demonstrate new skill, or explore a new attitude with the teacher and ask for feedback

Learning Contracts ● ● ● Does your teaching setting have a learning contract? If so, does it need to be modified or augmented to meet the needs of IMGs? If not, is the group interested in developing one or using one of the two examples provided?

The Canadian Learning Environment Better Practice Interpersonal competencies: • Communication skills • Ethics • Professionalism • Socio-cultural issues Self-directed learning Learning opportunity Identify the gap: • Knowledge • Skills • Attitudes Teacher questioning Feedback Learning contracts Expectations Current Practice

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Feedback ● Utilizing feedback is a crucial skill in the development of lifelong learning ● Feedback can identify both gaps & strengths ● The inaccuracy of self-assessment ● ● The differences between formative and summative evaluation Feedback will often be delivered in a ‘sandwich’

Feedback Sandwich What was done right What was done wrong or needs to be improved What to do next time

The Canadian Learning Environment Better Practice Interpersonal competencies: • Communication skills • Ethics • Professionalism • Socio-cultural issues Self-directed learning Learning opportunity Identify the gap: • Knowledge • Skills • Attitudes Teacher questioning Feedback Learning contracts Expectations Current Practice

Teacher Questioning “Teaching is not telling but questioning. ” Wilkerson, Armstrong, & Lesky, 1990 “The process of how we learn as physicians eclipses and surpasses the content of any factual data. ” Orientale, 1998 ● IMGs should be cued to the variable questions that teachers may ask

Assess & Expand Clinical Thinking - I ● Factual questions – ● What is the appropriate dose of Amoxil for this child? Broadening questions – Can you tell me the differential diagnosis for a chronic cough in this patient?

Assess & Expand Clinical Thinking - II ● Justifying questions – ● Hypothetical questions – ● What outcome would you expect from this treatment intervention? How would your treatment vary if this patient was 20 years older? Alternative questions – If the patient chooses not to follow your treatment plan, what might you expect?

Assess & Expand Clinical Thinking - III ● Attitudinal questions How did it make you feel when that patient refused your suggestions? – What could you have done to enhance compliance? – Have you let negative feelings about this patient impact on your clinical decisions? – Benzie, 1998

Teacher Questioning Tips ● ● Ensure sufficient ‘wait-time’ after posing questions. “Wait -time is the amount of time after an initial question has been posed before it is either repeated, rephrased or answered by the teacher. ” (Lesky & Borkan, 1990) Typically teachers only wait one second before speaking. Refrain from asking two questions simultaneously: one open-ended; the other leading. The second question aborts the problem solving generated by the open-ended question (e. g. What do you think is the cause of his abdominal pain? Do you think it could be renal colic? ).

The Canadian Learning Environment Better Practice Interpersonal competencies: • Communication skills • Ethics • Professionalism • Socio-cultural issues Self-directed learning Learning opportunity Identify the gap: • Knowledge • Skills • Attitudes Teacher questioning Feedback Learning contracts Expectations Current Practice

Learning Opportunities “A climate that discourages risk taking will also discourage verbal problem solving…. By acknowledging uncertainty, learners can be guided to explore alternatives and to evaluate critically what is known, rather than to focus exclusively on finding the right answer” Lesky & Borkan, 1990

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The Canadian Learning Environment Better Practice Interpersonal competencies: • Communication skills • Ethics • Professionalism • Socio-cultural issues Self-directed learning Learning opportunity Identify the gap: • Knowledge • Skills • Attitudes Teacher questioning Feedback Learning contracts Expectations Current Practice

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Self-Directed Learning WHAT IS IT? How would a teacher know you are self-directed?

Self-Directed Learning “It is the ability to identify the limits of one’s own knowledge and skills and to organize resources to learn more. ” Wilkerson et al. , 1990

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Competencies in Self-Directed Learning ● Be self motivating with respect to learning ● Diagnose learning needs realistically ● Translate learning needs into learning objectives ● Relate to teachers as facilitators or resources ● Identify resources appropriate to different kinds of learning objectives

Competencies in Self-Directed Learning ● ● Select effective strategies for using learning resources Apply new knowledge in practice settings Relate to peers collaboratively Be willing to evaluate the effectiveness of both the information and the process

Log of Resident Clinical Questions Date Question Asked Resident Question Review Date

Demonstrate Self-Directed Learning Through: ● ● ● Development of a learning contract for each rotation Initiation of a discussion at the start of each rotation to review the tasks and responsibilities of that rotation Discuss how feedback will be given Commit to a learning task and follow through Review new knowledge, demonstrate new skills, or explore attitudinal issues with your teacher

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Evaluation ● ● IMGs may have little or no experience with practice-based evaluations such as OSCEs, direct observation, or videotape review The breadth of skills assessed may be different

Can. MEDS Roles The Can. MEDS Roles Framework Professional Manager Medical Expert Health Advocate Communicato r Schola r Collaborator © 2001 -2005 The Royal College of Physicians and Surgeons of Canada

Four Principles of Family Medicine ● The family physician is a skilled clinician ● Family medicine is a community-based discipline ● ● The family physician is a resource to a defined population The patient-physician relationship is central to the role of the family physician

RIME Evaluation Framework ● REPORTER ● ● ● INTERPRETER ● ● ● Efficiently and accurately collect patient data Recognize normal from abnormal Identify and label new problems Communicate collected data orally and in writing Prioritize problems Follow up and interpret abnormal findings and tests Create differential diagnosis Prioritize a differential diagnosis Pangaro, 1999

RIME (Cont’d) ● Manager ● ● ● Educator ● ● ● Determine when action is necessary Choose most appropriate diagnostic test Choose most appropriate management strategy Customize a plan according to patient circumstances and preferences Identify knowledge gaps Share new knowledge with others Understand the use and limits of education in the care of patients Pangaro, 1999

Evaluation ● ● ● What level do you think you are at? How do you think teachers will evaluate the level you are at? What do you think you would need to do to move up to the next level?

Where Should You Be Along This Continuum? REPORTER End of medical school INTERPRETER Clerkship MANAGER First-year resident EDUCATOR Second-year resident Pangaro, 1999

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Evaluation Forms ● Format ● Interpretation

The “Bottom Line” ● Both feedback and evaluation areas of significant difficulty for many IMGs. They need to understand that these processes will not only include factual knowledge but also clinical reasoning, communication skills, selfdirectedness, reflection and critical appraisal

The Canadian Learning Environment Better Practice Interpersonal competencies: • Communication skills • Ethics • Professionalism • Socio-cultural issues Self-directed learning Learning opportunity Identify the gap: • Knowledge • Skills • Attitudes Teacher questioning Feedback Learning contracts Expectations Current Practice

Development of Interpersonal Competencies ● Communication skills ● Cultural issues ● Ethics and professionalism ● Socio-cultural issues

Communication Skills ● Patient-centered model of health care ● Team-based model of care ● Communication with colleagues, consultants & co-workers

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Socio-Cultural Issues ● ● Limited ethnic & cultural diversity in previous training Need to care for patients independent of practitioners’ personal, social & religious mores ● Role of family in illness & care ● Locus of control of illness ● Attitudes & approaches to death & dying

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Socio-Cultural Issues (Cont’d) ● Skill development around abortion, sexual orientation, sexuality, teen pregnancy, infertility, divorce ● Delivering bad news ● Gender equality ● Confidentiality ● Power differential

Ethics & Professionalism ● ● ● ● Behaviour towards patients who hold different beliefs and values Patient-centered care Confidentiality Dual relationships: treatment of family members and friends Relationships with the pharmaceutical industry Patient autonomy Power differentials within professional relationships

Ethics & Professionalism Risky situations: ● Physical exam ● Sexual history-taking ● Psychotherapy

Ethics & Professionalism Danger signals: ● ● ● ● Making exceptions for certain patients Seeking social contact with patients, or doing therapy in social situations Confiding sensitive personal information to patients, or being pressured to do so Daydreaming about the patient Accepting gifts from patients, or giving them Trying to impress the patient with personal "specialness“ Being gratified by a sense of power when a patient’s activity is controlled through intervention Wanting to "rescue" the patient Walsh, Dunn & Freeman, 1999

Resources

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Clinically… ● ● Learn how to present a patient clearly and succinctly Identify your differential diagnosis and how you have come to that decision ● Describe your plan ● Identify your learning gap ● ● Ask for direction …What else would be helpful for me to know? Learn how to write chart notes, discharge summaries, consult letters etc….

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Interpersonally… Teachers assume that: ● ● ● “If you don’t speak it is because you don’t know or don’t care” If you don’t know, you will say so BUT be clear about where you are stuck in your thinking If you disagree with a teacher or a fellow student you will say so. It is not considered disrespectful to question things but a sign of an active and enthusiastic learner

Teachers Will Assume That: ● ● ● You will share your ideas and experience about diagnosis and management Your previous experience will be helpful You probably have expertise in some areas of medicine that will exceed that of the teacher Expectations may be different from previous learning environments. It is important to explicitly clarify your dayto-day responsibilities & roles You are responsible for your learning with the teacher acting as facilitator rather than delivering content. You need to develop good information management skills

Feedback ● ● ● Feedback is about your growth as a learner not a reflection on you as a person Often there is no right answer in the issues we deal with, therefore, the process of reaching a decision takes on new importance In learning situations the teachers’ role is to assess your knowledge base & identify gaps or strengths…and to help you expand your clinical thinking

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