Language barriers and professional identity: A qualitative interview study of newly employed international medical doctors and Norwegian colleagues

Facilitating international medical graduates' acculturation: From theory to practice

CONTEXT

International medical graduates (IMGs) are forming an ever-increasing proportion of the medical workforce. Much of the discourse around IMGs is about their performance at work and interventions to improve it. This discourse, however, is rarely situated in the wider context of the experiences of IMGs as migrants despite the wider context of migration and acculturation being likely to have a significant impact on IMGs' well-being and, ultimately, performance at work.

OBJECTIVES

The objectives of this article were to (1) raise awareness of the inextricable broader context within which IMGs are situated as migrants; (2) outline the impact this context might have on IMGs' performance; (3) discuss literature from the social sciences related to acculturation that could better inform the way we view IMG transition and performance; (4) highlight how acculturation theory can help inform the design, implementation and evaluation of interventions to facilitate the transition of IMGs into the host country and the workplace; (5) list some interventions that can provide support; and (6) suggest theory driven lines of enquiry to study acculturation in IMGs and the impact related issues might have on performance.

METHODS

This is a cross-cutting edge review drawing on selected theory and literature from the social sciences to explore its relevance to IMGs.

CONCLUSION

The broader context of migration and acculturation should not be ignored when discussing IMG performance in the workplace or when instigating interventions to improve it. There is an urgent need to further evaluate the impact this broader context has on IMGs' well-being and performance.

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.

Understanding the cultural identity of EFL learners from the eco-linguistics perspective: evidence from students in arts college before and after the COVID-19 epidemic period

The identity development process has individual and societal components and is inherently intertwined with one's broader sociocultural milieu. The correlation between the personal and social aspects of an individual's identity considerably influences their behavior within their environment. This study examines cultural identity changes among English as a Foreign Language (EFL) students by conducting a questionnaire survey based on the anxiety/uncertainty management theory by Gudykunst (1995, 1998). The questionnaire was distributed twice: Study 1 used data from 483 students and Study 2 used data from 359 students. After each study, 20 students' descriptions of Chinese and Western cultures were analyzed in NVivo. Guided by the ecological research paradigm, this study examines the impact of individual differences on cultural identity at the macro-, meso-, exo-, and micro- levels. The findings suggest that social context can influence an individual's cultural identity, and cultural identity development accompanies being "oneself."

Linguistic coaching: a pilot study of one-to-one near-peer coaching for international GP trainees in Yorkshire

INTRODUCTION

International medical graduates (IMGs) have a higher rate of examination failure and are more likely to be referred to the regulator for professional performance issues than their UK-trained counterparts. Support for IMGs to reduce differential attainment takes many forms. A pilot study to assess the feasibility and utility of early intervention to increase the support available for IMGs entering general practice (GP) training was undertaken.

METHOD

IMGs entering GP training in one UK region were offered one-to-one, near-peer linguistic coaching during their first two weeks of training. A session focusing on cultural acclimatisation, local accent and dialect using mock patient consultations was delivered and evaluated.

RESULTS

The coaching was valued by the trainees and the intervention allowed very early identification of a trainee who needed further support. It was possible to identify such trainees using a non-medical volunteer student coach.

DISCUSSION

Use of a non-medical, near-peer coach for one-to-one linguistic support has not previously been described for IMGs. This pilot study confirms the acceptability and utility of this approach. Early identification of trainees requiring enhanced support allows targeted interventions in a time-pressured speciality training programme. Further study with a larger-scale and longer-term coaching programme, assessing trainee feedback and uptake of early supportive intervention is recommended.

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.

Doctors on the move 2: a qualitative study on the social integration of middle eastern physicians following their migration to Germany

Background

The integration of immigrating physicians has become a challenge for many societies and health care systems worldwide. Facilitating the integration process may benefit both the uptaking country and the immigrating physicians. Previous studies have approached this problem from a system integration perspective. The present study explores the degree of social integration of an exemplary group of Middle Eastern physicians following their migration to Germany from an individual perspective.

Methods

Based on social constructivist epistemology, a series of fifteen interviews and two focus groups with immigrated Middle Eastern physicians (n = 23, purposively sampled) were conducted between 2017 and 2020 in Germany. The audio recordings were transcribed, translated into English and analysed deductively based on Esser’s model of social integration, consisting of four dimensions: acculturation, positioning, interaction and identification.

Results

The social integration of the participants showed a multifaceted picture. The early phase was characterized by disorientation and trial and error. Cultural differences were of major importance. Acculturation was facilitated by German language acquisition and increased over time, although some cultural difficulties remained. Professional positioning was facilitated by the need for physicians and a relatively low-hurdle relicensing procedure. Interaction and identification depended on the efforts of the individual physicians.

Conclusions

This study provides a comprehensive picture of the individual social integration of Middle Eastern physicians in Germany. Language and cultural adaptation are identified as being of primary importance. Social integration can be facilitated through orientation programmes or cross-cultural training that benefits the uptaking countries as well as the immigrating physicians.

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.

Communication in Health Care: Impact of Language and Accent on Health Care Safety, Quality, and Patient Experience

Permanent or temporary migration results in communication issues related to language barriers. The migrant's mother tongue is often different from that of the host country. Even when the same language is spoken, communication barriers arise because of differences in accent. These communication barriers have a significant negative impact on migrants accessing health care and their ability to understand instructions and seek follow-up care. A multidisciplinary team often has professionals from various countries. These migrant health care professionals find it difficult to communicate with patients of the host country and with their colleagues. Communication barriers, therefore, result in miscommunication or no communication between health care professionals and between health care professionals and patients. This increases the risk of medical errors and impacts quality of care and patient safety. This review looks at the impact of communication barriers in health care and endeavors to find effective solutions.

Interprofessional collaboration in connection with a medical ship: nurses' experiences

AIMS AND OBJECTIVES

To describe nurses´ experiences of interprofessional collaboration (IPC) in connection with a medical ship offering primary health care in Papua New Guinea.

BACKGROUND

More than a third of the population in Papua New Guinea are living in severe poverty, resulting in serious and fatal diseases. Due to rough terrain and lack of infrastructure, most of them cannot benefit from health care in the cities. Thus, a medical ship is used since the sea route is one of the few possible ways to reach the people.

DESIGN

A qualitative study with an inductive and descriptive approach was performed, and content analysis of the data was used.

METHODS

In January 2018, eleven nurses from seven countries were interviewed onboard the medical ship assessing their experiences when performing IPC. The COREQ checklist for qualitative studies was applied in the conduct and reporting of this study.

RESULTS

Three generic categories emerged: Nurses' motivation to achieve the common goal of doing good using IPC; Nurses' view of performing IPC within special conditions; and Nurses' perception of their role in IPC. Overall, the IPC was perceived by the nurses as well functioning. Having a common goal, positive mindset and effective communication improved the team's collaboration. When these aspects were accomplished, the chances of overcoming the challenge of working in new circumstances and limited space with a newly formed team were increased.

CONCLUSION

Good collaboration within an interprofessional team required repeated sharing of information. This demonstrates the importance of communication and engagement to overcome existing challenges when working interprofessionally.

RELEVANCE TO CLINICAL PRACTICE

This study recommends the establishment of IPC for similar contexts such as onboard Youth With a Mission and ashore, as well as in disaster situations or home care where the healthcare professional must collaborate and adapt to new circumstances and prevailing situations.

A Review of Strategies for Enhancing Clarity and Reader Accessibility of Qualitative Research Results

Objective. To characterize elements of the results section of qualitative research reports that make findings more accessible to readers. Methods. Two analytical methods were used for this review. First, published reviews and textbooks written by experts outlining how to evaluate qualitative research were retrieved and reviewed to identify common elements that enhance clarity of the results section. In the second analysis, the authors analyzed the results sections of a subset of qualitative studies to identify, from a reader's point of view, aspects that enhanced and detracted from communication of the results. Findings. Four elements improve accessibility of the results section for readers of qualitative research reports. Content, the first element, describes what information the reader should look for in the results section. Style of results, the second element, identifies wording choices that improve reader accessibility and understanding. Narrative flow, the third element, describes a results section that flows smoothly and logically. Structural cohesiveness, the final element, outlines effective organization of the results section. Results. While authors take several approaches to the presentation of results in qualitative research reports, some strategies appear to be more common and effective than others. The efficient presentation of results can impact a reader's assessment of the quality and credibility of a study. Identified content and stylistic elements should be considered by authors hoping to make the results of their qualitative research more accessible and comprehensible to readers.

Migrant physicians' entrance and advancement in the Swedish medical labour market: a cross-sectional study

BACKGROUND

Worldwide, physicians are migrating to new countries and want to practise their profession. However, they may experience difficulties doing so. To optimise and accelerate their entrance into and advancement within the Swedish healthcare system, there is an urgent need to explore how they are currently doing so, as their competences should be put to use without any unnecessary delay. The aim of the study was to explore how migrant physicians with a medical degree from outside EU/EEA enter and advance within the medical labour market in Sweden and to identify perceived barriers and facilitating aspects in the process. The empirical findings are discussed in light of Bourdieu's concept symbolic capital as adapted in the Swedish medical field.

METHODS

A cross-sectional study with a self-administrated questionnaire was disseminated. A sample of 498 migrant physicians were identified. Descriptive statistical analysis and qualitative thematic analysis were used to analyse the data.

RESULTS

The response rate was 57% (n = 283). Respondents mainly found their first positions via spontaneous job applications, during internships, while participating in an educational intervention or via personal contacts. Perceived barriers to entering and advancing within the medical field in Sweden were mainly related to having a medical degree from and/or originating from another country, which could in turn represent discrimination and/or having one's competence undervalued as a result. Facilitating aspects included having or developing contacts in Swedish healthcare and gaining proficiency or fluency in the Swedish language.

CONCLUSIONS

When MPs find their first positions, the contacts they have developed appear to play a role, and when advancing in their positions, the active development of a variety of contacts seems to be beneficial. MPs experience a variety of barriers to entering and advancing within the field that could be related to discrimination. Many MPs perceived having their competences undervalued due to their origin or to being educated abroad. Based on the respondents' experiences, our interpretation is that MPs as a group are hierarchically positioned lower in the Swedish medical field than physicians trained in the country. Facilitating aspects included educational interventions, having contacts and developing language skills. For optimal entry into the labour market, it is vitally important for MPs to learn the new language and obtain a job or internship in the field as soon as possible.

International medical graduates and general practice training: How do educational leaders facilitate the transition from new migrant to local family doctor?

Objectives: To document medical educators' experience and initiatives in training international medical graduates (IMGs) to become general practitioners (GP). Design: Qualitative social-constructivist emergent design with descriptive and interpretive analyses. Setting: GP vocational training in Australia, Canada, Ireland, New Zealand, the Netherlands, and UK. Participants: Twenty-eight leaders of GP training. Intervention: Data collected from public documents, published literature and 27 semi-structured interviews. Main outcome measures: Tensions in training and innovations in response to these tensions. Results: Medical educators identified tension in teaching IMGs as it could be different to teaching domestic graduates in any or all aspects of a training program. They felt an ethical responsibility to support IMGs to provide quality health care in their adopted country but faced multiple challenges to achieve this. They described initiatives to address these throughout GP training. Conclusions: IMG's differing educational needs will benefit from flexible individualized adaptation of training programs.

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

Many international medical graduates (IMGs) enter North American residency programs every year. The Canadian IMG physician pool increasingly includes Canadian-born IMGs (C-IMGs) along with Immigrant-IMGs (I-IMGs). Similar trends exist in the United States. Our objective was to understand the similarities and differences in the challenges faced by both I-IMGs and C-IMGs during residency to identify actionable recommendations to support them during this critical time. We performed a multiple case study of IMGs' experiences at a large Canadian university. Within our two descriptive cases (I-IMGs, C-IMGs) we iteratively conducted twenty-two semi-structured interviews; we thematically analyzed our data within, between, and across both cases to understand challenges to IMGs' integration and opportunities for curricular innovations to facilitate their adaptation process. Research team members with different perspectives contributed reflexively to the thematic analysis. Participants identified key differences between medical culture and knowledge expected in Canada and the health systems and curricula in which they originally trained. I-IMG and C-IMG participants perceived two major challenges: discrimination because of negative labelling as IMGs and difficulties navigating their initial residency months. C-IMGs described a third challenge: frustration around the focus on the needs of I-IMGs. Participants from both groups identified two major opportunities: their desire to help other IMGs and a need for mentorship. I-IMGs and C-IMGs face diverse challenges during their training, including disorientation and discrimination. We identified specific objectives to inform the design of curriculum and support services that residency programs can offer trainees as well as important targets for resident education and faculty development.

Migrant physicians' conceptions of working in rural and remote areas in Sweden: A qualitative study

Objective

To explore migrant physicians’ conceptions about working in rural and remote areas in Sweden to understand what influences their motivation to work in these areas.

Method and material

The study employed a qualitative approach with semi-structured interviews with 24 migrant physicians. Transcripts were thematically analysed.

Results

Conceptions were identified about foremost work content and tasks, and about living in rural and remote areas. Work content and tasks related to the health care systems, type of health care facility, duties, specialty, resources, patient population, colleagues, and professional development. Conceptions about living concerned geographical characteristics, people living in rural and remote areas, opportunities for travelling, family, leisure activities, social life, and language skills. Conceptions seemed to be influenced by individual, professional and societal aspects from both previous countries and Sweden. Conceptions and biographical aspects both appeared to affect motivation.

Discussion

Motivation regarding working in rural and remote areas appeared to be influenced by conceptions of these areas. A specific type of place could be understood as being able to provide (or not) the external conditions needed for fulfilling needs and reaching goals, whether professional or personal, and as a tool for reaching or facilitating the achievement of these. Conceptions of an area can hence affect motivation and choices for where to work and live. However, biographical aspects also impact motivation. Our results indicate that positive rural experience in the recipient country might be a predictor for motivation.

Conclusion

Professional and personal life and are intertwined. Conceptions about an area influence willingness to work there. Willingness is also affected by, and intertwined with, other aspects such as previous experiences, age, marital status and family circumstances.

Mentality Differences in the Field of Medicine: Challenges in Cross-Cultural Collaborations in Austrian and German Hospitals between Native Physicians and Immigrated Colleagues from Poland and Hungary

Within the last decades, studies about characteristics of national culture have mostly been focused on the business sector. In other industries, like the field of medicine, research about mentality differences is still in its infancy. Due to increased international job mobility of physicians around the globe, especially within the European Union, it is considered necessary to draw more attention at this topic. For this purpose, some studies are presented initially that have already addressed the issue of cultural differences in the field of medicine. By extracting their most crucial findings, an overview regarding the state-of-the- art is provided. Based on these findings, a design for qualitative research is modelled that is aimed at closing these knowledge gaps. As a first step in this context, it is explained which perspective is considered to be the most promising in terms of generating in-depth insights. Moreover, a possible approach towards constructing mentalities beyond a national level is introduced. This part goes hand in hand with suggesting two mentalities whose comparison is regarded to make sense. These mentalities are going to be an Austro-Germanic Mentality (physicians from Austria and Germany) and a Magyar- Slavic Mentality (physicians from Hungary and Poland). Subsequently, the author is going to recommend some dimensions of established cultural models that should be taken into account when designing an interview outline. Beyond that, some preliminary findings of an ongoing study with Eastern European doctors who are working in Austrian and German hospitals are presented. So far, it has become obvious that there is a remarkable different approach towards hierarchy and leadership, personal relationships with colleagues as well as task-fulfillment and personal responsibility. In the last part of this paper, the author emphasizes the positive effects that are expected to occur when awareness in terms of mentality differences is raised and how they could be achieved.

Dealing with foreign cultural paradigms: A systematic review on intercultural challenges of international medical graduates

OBJECTIVES

An increasing number of International Medical Graduates (IMG), who are defined to be physicians working in a country other than their country of origin and training, immigrate to Western countries. In order to ensure safe and high-quality patient care, they have to take medical and language tests. This systematic review aims to (1) collect all empiric research on intercultural communication of IMGs in medical settings, (2) identify and categorize all text passages mentioning intercultural issues in the included studies, and (3) describe the most commonly reported intercultural areas of communication of IMGs.

METHODS

This review was based on the PRISMA-Guidelines for systematic reviews. We conducted a broad and systematic electronic literature search for empiric research in the following databases: MEDLINE, BIOSIS Citation Index, BIOSIS Previews, KCI-Korean Journal Database and SciELO Citation Index. The search results were synthesized and analyzed with the aid of coding systems. These coding systems were based on textual analysis and derived from the themes and topics of the results and discussion sections from the included studies. A quality assessment was performed, comparing the studies with their corresponding checklist (COREQ or STROBE). Textual results of the studies were extracted and categorized.

RESULTS

Among 10,630 search results, 47 studies were identified for analysis. 31 studies were qualitative, 12 quantitative and 4 studies used mixed methods. The quality assessment revealed a low level of quality of the studies in general. The following intercultural problems were identified: IMGs were not familiar with shared decision-making and lower hierarchies in the health care system in general. They had difficulties with patient-centered care, the subtleties of the foreign language and with the organizational structures of the new health care system. In addition, they described the medical education in their home countries as science-oriented, without focusing on psychosocial aspects.

CONCLUSION

There is a need for a better training of IMGs on culture-related and not culture-related topics in the new workplace country. The topics that emerged in this review constitute a basis for developing these courses. Further empiric research is needed to describe the findings of this review more precisely and should be in accordance with the existing reporting guidelines.