Moving beyond orientations: a multiple case study of the residency experiences of Canadian-born and immigrant international medical graduates

Discrimination faced by radiology residents: an analysis of experiences and mitigation strategies

RATIONALE AND OBJECTIVES

Literature shows that discrimination has been pervasive in the field of medicine. The aim of this study was to collect experiences related to discrimination among US radiology residents, including type and source, as well as the residents' perception on lectures about discrimination and harassment. We also explored the barriers to reporting, and suggested strategies to overcome them.

MATERIAL AND METHODS

Following Institutional Review Board (IRB) approval, an online survey was sent to program directors and coordinators across the US, who were asked to forward the link to their radiology residents. A reminder email was sent over a period of 4 months. The participants were reassured the survey was confidential and anonymous.

RESULTS

Among the respondents, the most reported types of discrimination were based in gender, race and nationality, the majority of which not being reported. The most common perpetrators were attending radiologists, co-residents, technologists, and patients. The main barriers for reporting were fear of retaliation, confidentiality concerns, and skepticism about a positive outcome.

CONCLUSION

Our study examines some experiences of discrimination shared by residents during their training, with gender and race being the most common causes. This sheds light into a hidden and unspoken issue and highlights the need for more active discussions in radiology on microaggressions and implicit bias. Our data can guide future studies as well as residency programs to build effective strategies to address discrimination, aiming for sustainable changes.

An opportunity to be grateful for? Exploring discourses about international medical graduates from India and Pakistan to the UK between 1960 and 1980

INTRODUCTION

Following India and Pakistan gaining independence from British colonial rule, many doctors from these countries migrated to the UK and supported its fledgling National Health Service (NHS). Although this contribution is now widely celebrated, these doctors often faced hardship and hostility at the time and continue to face discrimination and racism in UK medical education. This study sought to examine discursive framings about Indian and Pakistani International Medical Graduates (IPIMGs) in the early period of their migration to the UK, between 1960 and 1980.

METHODS

We assembled a textual archive of publications relating to IPIMGs in the UK during this time period in The BMJ. We employed critical discourse analysis to examine knowledge and power relations in these texts, drawing on postcolonialism through the contrapuntal approach developed by Edward Said.

RESULTS

The dominant discourse in this archive was one of opportunity. This included the opportunity for training, which was not available to IPIMGs in an equitable way, the missed opportunity to frame IPIMGs as saviours of the NHS rather than 'cheap labour', and the opportunity these doctors were framed to be held by being in the 'superior' British system, for which they should be grateful. Notably, there was also an opportunity to oppose, as IPIMGs challenged notions of incompetence directed at them.

CONCLUSION

As IPIMGs in the UK continue to face discrimination, we shed light on how their cultural positioning has been historically founded and engrained in the imagination of the British medical profession by examining discursive trends to uncover historical tensions and contradictions.

Mentoring to address differential attainment of international medical graduates in GP training

INTRODUCTION

International Medical Graduates (IMGs) form an important and valued part of the United Kingdom's (UK) medical workforce but many experience difficult transitions into the National Health Service workforce. Mentoring could support IMGs as they transition into their role as General Practice (GP) trainees but there is a lack of evidence about whether mentoring is an effective intervention for this group.

AIM

To evaluate the effectiveness of the NHS Education for Scotland (NES) GP mentoring programme from the perspective of mentors and mentees.

METHOD

Twelve medical educators (the mentors) provided mentoring to 19 IMG GP trainees (the mentees) who were within their first six months of entering GP training in Scotland. Each mentee received four 60-minute mentoring sessions via video conferencing.

RESULTS

Mentoring provided tailored support to assist IMG GP trainees' holistic transition into UK General Practice. Mentees appreciated talking to a non-supervisor, receiving non-judgemental support and protected time with a supportive listener to overcome challenges. This had a positive impact, even for those who did not anticipate the need for such support. Mentors supported diverse needs and tailored meetings, experiencing a distinct shift from previous supervisor roles. Their diverse experience enhanced their role and they developed new skills.

CONCLUSION

Mentoring could provide significant support to IMG GP trainees but comes with certain challenges. Future research should evaluate the long-term impact of the NES GP IMG mentoring programme.

Differences between international medical graduates and Canadian medical graduates in a medical learning environment: From matching to residency and beyond

Objective

To determine the differences between international medical graduates (IMG) and canadian medical graduates (CMG) in the medical learning environment (MLE) as there is progression from matching to residency and beyond.

Method

A narrative literature review was done using the search engines pubmed, medline and embase on publications from 2000 to 2021 comparing IMG to CMG and those that compared IMG to non IMG in international publications were also considered.

Results

The IMGs are offered less residency program positions compared to CMGs during the CaRMS selection process and specifically less in specialty programs. Amongst the article, 66% of IMGs compared to 90% of CMG were successful in the certification examination of the college of family physicians of Canada. A US article on the other hand found similarities in performance of USMGs and IMGs in a surgical residency program.

Conclusion

A lot of IMG face several challenges including perceived systemic and individual discrimination, lack of mentorship and poor ability to navigate after immigration even after they are matched into a Canadian residency program. These are significant issues that should be dealt with to enable increase success and survival of IMGs in the MLE.

Exploring how immigrant international medical graduates successfully manage complex sociocultural challenges

Background

While immigrant international medical graduates (I-IMGs) contribute significantly to the physician workforce in North America, researchers have highlighted the myriad of ways sociocultural challenges can negatively impact their success. Conceptual understanding that unpacks the complex processes of how I-IMGs effectively manage sociocultural challenges is relatively sparse. In addressing this critical knowledge gap, this study explored how I-IMGs successfully manage sociocultural differences as postgraduate residents.

Methods

We interviewed eleven I-IMGs from diverse backgrounds who are in training or recently trained in a distributed multi-site postgraduate medical training program in Canada. We used the lens of sociocultural learning theory to gain insights into the processes of how I-IMGs describe successful management of sociocultural challenges.

Results

The overarching storyline of participants emphasized that their experiences were humbling as they grappled with inner struggles, emotions, and vulnerabilities while embracing the ambiguity of not knowing what was expected of them. The following dominant themes from their narratives encapsulate the salient processes for how I-IMGs conceptualize and successfully manage sociocultural challenges: 1) successfully navigating transitions; 2) resisting or altering elements of prior sociocultural norms while embracing the new; 3) living and being in community and having supportive social networks; 4) risk taking to self-advocate and actively seek help.

Conclusion

Understanding the strengths and positive strategies for how I-IMGs interface with complex sociocultural challenges has application for medical training institutions. Our insights suggest the need for practical, effective, and continuous assistance within I-IMG training programs to better support future trainees dealing with sociocultural challenges.

Is it really a challenge to find positive attributes for international medical graduates predictive of success in family medicine residency?

In their paper "Challenges with international medical graduate selection: finding positive attributes predictive of success in family medicine residency," (BMC Prim Care 23(256):2-9, 2022) the authors report on their research into qualitative attributes that positively correspond to success in residency with the objective of assisting in the selection of International Medical Graduate (IMG) residents most likely to achieve success in family medicine residency. The authors found that positive predictors of IMG residents' success were: presence of a positive attitude, proficient communication skills, high level of clinical knowledge, and trainability. The authors conclude that selecting IMG residents who possess these attributes will result in residents developing increased aptitudes for patient care. A careful reading of the paper raises a number of concerns. MacFarlane (Can Med Educ J 12(4):132-40, 2021) points out that IMGs are already marginalized in the residency selection process. Our concern is that this paper may contribute to this marginalization through a tone of negativity or bias against IMGs and the use of biased language throughout the paper that tends to cast IMGs as being inferior and somehow less well prepared for residency than Canadian Medical Graduates (CMGs). We argue that the proposed predictors are generic and equally relevant to both CMGs and IMGs. In focusing on these predictors in IMGs specifically, the paper appears to imply, without evidence, that IMGs are inadequate in the identified areas. After reviewing the paper's references, the existing literature, and an analysis of language used, we conclude that IMGs are capable candidates for residency, and that the qualitative attributes outlined in the paper offer little utility for the selection of IMG residents relative to CMG residents.

Inequitable treatment as perceived by international medical graduates (IMGs): a scoping review

OBJECTIVES

This scoping review seeks to detail experiences of inequitable treatment, as self-reported by international medical graduates (IMGs), across time and location.

DESIGN

Scoping review.

SEARCH STRATEGY

Three academic medical databases (MEDLINE, SCOPUS and PSYCINFO) and grey literature (GOOGLE SCHOLAR) were systematically searched for studies reporting first-hand IMG experiences of perceived inequitable treatment in the workplace: discrimination, prejudice or bias. Original (in English) qualitative, quantitative, mixed studies or inquiry-based reports from inception until 31 December 2022, which documented direct involvement of IMGs in the data were eligible for inclusion in the review. Systematic reviews, scoping reviews, letters, editorials, news items and commentaries were excluded. Study characteristics and common themes were identified and analysed through an iterative process.

RESULTS

We found 33 publications representing 31 studies from USA, Australia, UK, Canada, Germany, Finland, South Africa, Austria, Ireland and Saudi Arabia, published between 1982 and 2022. Common themes identified by extraction were: (1) inadequate professional recognition, including unmatched assigned work or pay; (2) perceived lack of choice and opportunities such as limited freedoms and perceived control over own future; (3) marginalisation-subtle interpersonal exclusions, stereotypes and stigma; (4) favouring of local graduates; (5) verbal insults, culturally or racially insensitive or offensive comments; and (6) harsher sanctions. Other themes identified were effects on well-being and proposed solutions to inequity.

CONCLUSIONS

This study found evidence that IMGs believe they are subject to numerous common inequitable workplace experiences and that these experiences have self-reported repercussions on well-being and career trajectory. Further research is needed to substantiate correlations and causality in relation to outcomes of well-being and differential career attainment. Furthermore, research into support for IMGs and the creation of more equitable workforce environments is also recommended.

Career development of international medical graduates in Canada: status of the unmatched

With limited residency positions, the majority of international medical graduates living in Canada and other developed countries cannot work as physicians. The educational experience and career development of unmatched international medical graduates (those who are not matched to a residency position) residing in Canada have never been studied. Through an innovative collaboration of provincial international medical graduate organizations, we launched an online survey targeting the career development of unmatched international medical graduates, with 356 survey responses entering data analysis. Respondents reported that at the early career planning stage, close to a third had not had adequate knowledge of their career prospects in Canada. Although official resources are available, most respondents found that the information did not match well with reality. After arriving in Canada, educational resources for unmatched international medical graduates are scarce. The majority of them work in healthcare-related fields but reported significant difficulties finding these positions, and there were limited career training opportunities. Among respondents who were no longer pursuing residency positions and had moved on to alternate career paths, we found, unexpectedly, that 69% of them reported previous residency application experience did not contribute to their current occupation, and most were not satisfied with their current career status and continuing education opportunities. In conclusion, the unmatched international medical graduates could serve as a vital reservoir of skilled medical professionals to serve the community, especially during public health crises. Continuing education and career support of unmatched international medical graduates are crucial for their career development and should be an area of priority for policymakers. Career support, especially for alternative career paths, can be built on the current services that exist in most provinces in Canada. In addition, novel online and social media tools can be utilized to increase the outreach of these programs.

Migrant physicians' unlocking of gateways to practise their knowledge: A qualitative quasi-longitudinal study

This study explores the establishment experiences of physicians in the Swedish medical context who have been trained outside the European Union. The study used a qualitative approach with a quasi-longitudinal research design. The data were gathered via 63 semi-structured interviews with migrant physicians at three different periods. The data were analysed using qualitative thematic content analysis, adopting the theory on the context dependence of knowledge, which includes different forms of knowledge as sensitising concepts in the discussion. The MPs perceived themselves as having the medical knowledge (encoded knowledge) needed to work in Sweden. However, they perceived that they needed to develop knowledge of how to use the encoded knowledge in the Swedish medical context. The needed knowledge was thus foremost encultured, embedded, embodied, or embrained. The results are presented in the following themes: medical knowledge; knowledge of the healthcare system and its variations; knowledge of administrative routines; understanding the role as a physician, interaction and hierarchies between physicians and other healthcare staff; understanding the interaction and hierarchies between physicians and patients; and knowledge of the Swedish language. Knowledge, as described in the themes, function as gateways that needs to be unlocked for practising medicine in a new context. Embedded, embrained, embodied, and encultured knowledge interact and are interdependent, and the different forms of knowledge work as gateways to other forms of knowledge, and thus, they open for each other. However, to pass the gateways, managing the common language is important. We conclude that language is an enabler and a key to unlocking gateways to practise.

Challenges with international medical graduate selection: finding positive attributes predictive of success in family medicine residency

Background

Criteria to select residents most likely to succeed, other than proficiency of their medical knowledge, is a challenge facing preceptors. International Medical Graduates (IMGs) play an integral role in mitigating the high demand for family medicine physicians across Canada. Thus, selecting IMG candidates that have a high probability of succeeding in Canadian educational settings is important. The purpose of this study is to elucidate qualitative attributes that positively correspond to success in residency, to ultimately assist in the selection of IMG residents most likely to achieve family medicine residency.

Methods

Interviews of 13 family medicine preceptors from some of the largest IMG training sites in Canada were performed to collect original data. The data was coded in tandem sequences using standardized coding techniques to increase robustness of results.

Results

The identified positive predictors of an IMG residents’ success are: presence of a positive attitude, proficient communication skills, high level of clinical knowledge, trainability.

Conclusions

The results provide adequate guidelines to assist in selection of IMG residents. Canada is a unique sociocultural setting where standardized selection methods of IMGs have not been employed. By selecting IMG residents who possess these attributes upon inception of residency, benefits of instruction will be maximized and result in residents developing increased aptitudes for patient care.

Perceptions of interventional radiology amongst international medical graduates

AIM

To determine perceptions of interventional radiology (IR) amongst international medical graduates (IMGs) in the UK.

MATERIALS AND METHODS

A survey was undertaken of Trust-grade IMGs at a hospital in the UK. The data were collected using Google Forms and analysed using Microsoft Excel, with free-text responses grouped to mentorship, teaching, exposure, and taster-week themes.

RESULTS

Thirty-two percent of the respondents were likely to pursue a career in IR. Eighty-four percent did not have a radiology rotation after graduation, with 20% having a taster week in radiology. Of those likely to pursue a career in IR, 31% had completed a taster week in radiology. Respondents described IR exposure as minimal at 54%. Mentorship, teaching, exposure, and taster week were the themes of the free-text responses.

CONCLUSION

A targeted approach is needed to raise awareness and knowledge of IR as a career choice amongst IMGs. Trusts and departments must remove obstacles to organising taster weeks. IR needs to do a better job of educating IMGs and explaining the IR training pathway. Mentorship of IMGs is a simple tool for introducing and recruiting talent to the IR speciality.

International medical graduates' experiences before and after migration: A meta-ethnography of qualitative studies

INTRODUCTION

International medical graduates (IMGs) represent a large portion of practising doctors in many countries. Many experience difficulties, including higher rates of complaints against them and lower exam pass rates. The UK's General Medical Council (GMC) recently set targets to 'eliminate disproportionate complaints' and 'eradicate disadvantage and discrimination in medical education'. Our timely meta-ethnography aimed to synthesise existing qualitative literature on the wider personal and professional experiences of IMGs to identify factors affecting IMGs' professional practice (either directly or indirectly).

METHODS

In September 2019, we systematically searched Medline, Embase, Cochrane, PsycINFO, ERIC and EdResearch for peer-reviewed qualitative and mixed-methods articles that described experiences of IMGs. We extracted participant quotes and authors' themes from included articles and used the technique of meta-ethnography to synthesise the data and develop new overarching concepts.

RESULTS

Of the 1613 articles identified, 57 met our inclusion criteria. In total, the articles corresponded to 46 studies that described the experiences of 1142 IMGs practising in all six continents in a range of settings, including primary and secondary care. We developed five key concepts: migration dimensions (issues considered by IMGs when migrating), a challenging start (the stressful early period), degree of dissonance (between the IMG and host country in relation to the four main barriers of language, culture, medical education and belonging), levelling the playing field (interventions to reduce the impact of the barriers) and survive then thrive (adjustments IMGs made). A conceptual model that brings these constructs together in a line of argument is presented.

CONCLUSIONS

This meta-ethnography, based on a large amount of diverse qualitative studies, is the first to provide a comprehensive picture of the experiences and challenges that IMGs face before and after migration. Our results should be used to guide the development of interventions aiming to support IMGs and meet the GMC targets.

(Re)producing "Whiteness" in Health Care: A Spatial Analysis of the Critical Literature on the Integration of Internationally Educated Health Care Professionals in the Canadian Workforce

PURPOSE

There is a gap in the literature to understand how professionalizing systems intersect with socioeconomic and political realities such as globalization to (re)produce social inequities between those trained locally and those trained abroad. In this critical review, the question of how systemic racism is reproduced in health care is addressed.

METHOD

Electronic databases and nontraditional avenues for searching literature such as reference chaining and discussions with experts were employed to build an archive of texts related to integration of internationally educated health care professionals (IEHPs) into the workforce. Data related to workplace racialization were sought out, particularly those that used antiracist and postcolonial approaches. Rather than an exhaustive summary of the data, a critical review contributes to theory building and a spatial analysis was overlayed on the critical literature of IEHP integration to conceptualize the material effects of the convergence of globalization and professional systems.

RESULTS

The critical review suggests that professions maintain their value and social status through discourses of "Canadianness" that maintain the homogeneity of professional spaces through social closure mechanisms of credential nonrecognition and resocialization. Power relations are maintained through mechanisms of workplace racialization/spatialization and surveillance which operate through discourses of "foreign-trainedness."

CONCLUSIONS

Movement of professionals supports a professional system that on the surface values diversity while maintaining its social status and power through the (re)production of the discourse of "Whiteness." The analysis shows how in the process domestic graduates are emplaced as the "rightful" citizens of professional paces while IEHPs are marginalized in the workforce.

Journey into the unknown: considering the international medical graduate perspective on the road to Canadian residency during the COVID-19 pandemic

The COVID-19 pandemic has had a tremendous effect on education programs worldwide, including medical education. Particularly, International Medical Graduates (IMGs) planning to pursue residency training in Canada have been profoundly impacted. Cancellation of away electives, as well as changes to the format, timeline, and requirements of mandatory medical licensing exams has left IMG residency applicants in uncharted territory. Given that IMGs comprise up to 25% of the Canadian healthcare force, and often are based in underserviced areas, the licensure and eligibility of IMGs to continue to enter the Canadian healthcare force is of the utmost importance in the midst of the COVID-19 pandemic. As the pandemic evolves, it is imperative that key decision makers and stakeholders continue to consider the downstream effect for IMGs and their eligibility to practice in Canada.

Dismantling the master's house: new ways of knowing for equity and social justice in health professions education

Health professions education (HPE) is built on a structural foundation of modernity based on Eurocentric epistemologies. This foundation privileges certain forms of evidence and ways of knowing and is implicated in how dominant models of HPE curricula and healthcare practice position concepts of knowledge, equity, and social justice. This invited perspectives paper frames this contemporary HPE as the "Master's House", utilizing a term referenced from the writings of Audre Lorde. It examines the theoretical underpinnings of the "Master's House" through the frame of Quijano's concept of the Colonial Matrix of Power (employing examples of coloniality, race, and sex/gender). It concludes by exploring possibilities for how these Eurocentric structures may be dismantled, with reflection and discussion on the implications and opportunities of this work in praxis.

Comparison of the Professionalism Behaviours of Medical Students from Four GCC Universities with Single-gender and Co-educational Learning Climates

Background:

Medical professionalism is a multi-dimensional construct that is viewed differently across institutions. Such variations might be related to diverse cultural and societal characteristics of learners and faculty.

Objectives:

This study determined whether differences exist between proposed sanctions for a one-time academic integrity infraction associated with unprofessional behaviors. We selected four medical schools with either single-gender or co-educational learning environments in the Gulf Cooperation Council (GCC) countries.

Methods:

The 34-statement Dundee Polyprofessionalism Inventory I was disseminated to all medical students across years in selected institutions. Descriptive and inferential statistical analyses were conducted, and median scores were used to determine the respondents’ proposed sanctions.

Results:

Of the 1941 invitees, 1313 students responded (response rate of 68%). Significant similarity, as recorded by median sanction scores was recorded for 21 (62%) of the 34 inventory items from two medical schools. However, significant differences of one level of difference between all the median sanction scores for single-gender and co-educational students were found for 32% of inventory items. In co-educational schools, males were stricter than females for 9% and seniors were stricter than juniors for 12% of the inventory items. In contrast, in single-gender schools, females were stricter than males for only 6% of the inventory and seniors were more lenient than juniors for another 6% of the inventory.

Conclusions:

This study reports significant congruence and some differences in medical students’ perceptions of unprofessional behaviors. Educators are urged to develop a unified framework for enforcing sanctions to unprofessional behaviors.