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Bhugra D, Smith AJ, Ventriglio A, Rao N, Ng R, Javed A, Chisolm MS, Malhi G, Kar A, Chumakov E, Liebrenz M. World Psychiatric Association-Asian Journal of Psychiatry Commission on the Mental Health and Wellbeing of International Medical Graduates. Asian J Psychiatr 2024; 93:103943. [PMID: 38342035 DOI: 10.1016/j.ajp.2024.103943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 01/05/2024] [Accepted: 01/31/2024] [Indexed: 02/13/2024]
Abstract
Historically, doctors have migrated for a range of personal, educational, economic, and political reasons. Likewise, medical students from many countries have moved abroad to complete their training and education and may or may not return to their country of origin. Within this context, globalisation has had a major impact on medical education and healthcare workforces, contributing to recent migration trends. Globalisation is a complex phenomenon with positive and negative outcomes. For example, lower-income countries are regularly losing doctors to higher-income areas, thereby exacerbating strains on existing services. Across various national healthcare settings, migrating International Medical Graduates (IMGs) can face socioenvironmental and psychosocial pressures, which can lead to lower mental wellbeing and undermine their contributions to clinical care. Rates of stress and burnout are generally increasing for doctors and medical students. For IMGs, stressors related to migration, acculturation, and adjustment are not dissimilar to other migrants but may carry with them specific nuances. Accordingly, this Commission will explore the history of IMG trends and the challenges faced by IMGs, proposing recommendations and solutions to support their mental health and wellbeing.
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Affiliation(s)
- Dinesh Bhugra
- Institute of Psychiatry, Psychology and Neurosciences, Kings College London, De Crespigny Park, London SE5 8AF, UK.
| | - Alexander J Smith
- Department of Forensic Psychiatry, University of Bern, Bern, Switzerland
| | | | - Nyapati Rao
- Stony Brook University Health Sciences Center School of Medicine, New York, USA
| | - Roger Ng
- World Psychiatric Association, Geneva, Switzerland
| | - Afzal Javed
- World Psychiatric Association, Geneva, Switzerland
| | | | - Gin Malhi
- School of Psychiatry, University of Sydney, Sydney, Australia
| | - Anindya Kar
- Advanced Neuropsychiatry Institute, Kolkata, India
| | - Egor Chumakov
- Department of Psychiatry & Addiction, St Petersburg State University, St Petersburg, Russia
| | - Michael Liebrenz
- Department of Forensic Psychiatry, University of Bern, Bern, Switzerland
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Mannes MM, Thornley DJ, Wilkinson TJ. Cross-cultural code-switching - the impact on international medical graduates in New Zealand. BMC MEDICAL EDUCATION 2023; 23:920. [PMID: 38053141 DOI: 10.1186/s12909-023-04900-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 11/24/2023] [Indexed: 12/07/2023]
Abstract
BACKGROUND New Zealand relies on International Medical Graduates (IMGs); however, the retention of IMGs is not optimal. This research uses a lens of cross-cultural code-switching to explore how professional and cultural differences impact on International Medical Graduates' (IMGs') journeys to practise effectively and remain in New Zealand. METHODS Utilising theory-informing inductive analysis within a constructivist approach, framework analysis was conducted following 14 face-to-face interviews with IMGs. The analysis then explored the degree to which their experiences could be explained by cross-cultural code-switching's psychological challenges (authenticity, competence, and resentment). RESULTS Analysis showed there was an expectation for IMGs to code-switch. The greater the cultural and professional difference of IMGs (compared to New Zealand), the greater the intensity of psychological challenges experienced when switching. Moreover, IMGs received minimal support, making it difficult to overcome psychological challenges, especially the competence challenge. This led to feelings of frustration and vulnerability. Code-switching could also explain why complaints about IMGs were more likely when IMGs were stressed or tired. CONCLUSION Cross-cultural code-switching can be used to explain and identify how cultural differences cause psychological challenges. These findings inform how programmes can better support IMGs in orientation and ongoing training. Additionally, establishing, and allocating IMG cultural mentors would assist in addressing IMGs' vulnerability and isolation. With this support, the journey may prove more manageable and encourage IMGs to continue practising in their adopted country.
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Affiliation(s)
- Mariska M Mannes
- School of Social Sciences, University of Otago Dunedin, PO Box 56, Dunedin, 9054, New Zealand.
| | - Davinia J Thornley
- School of Social Sciences - Media, Film and Communication, University of Otago Dunedin, Dunedin, New Zealand
| | - Tim J Wilkinson
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
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Marthyman A, Nimmon L. Exploring how immigrant international medical graduates successfully manage complex sociocultural challenges. CANADIAN MEDICAL EDUCATION JOURNAL 2023; 14:40-50. [PMID: 38226312 PMCID: PMC10787855 DOI: 10.36834/cmej.76244] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/17/2024]
Abstract
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.
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Affiliation(s)
- Azaria Marthyman
- Centre for Health Education Scholarship (CHES), Faculty of Medicine, University of British Columbia, British Columbia, Canada
- Department of Family Practice, Faculty of Medicine, University of British Columbia, British Columbia, Canada
| | - Laura Nimmon
- Centre for Health Education Scholarship (CHES), Faculty of Medicine, University of British Columbia, British Columbia, Canada
- Department of Occupational Science and Occupational Therapy, Faculty of Medicine, University of British Columbia, British Columbia, Canada
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Jackson D, Brady J, Dawkins D. Positioning, power and agency in postgraduate primary care supervision: a study of trainee narratives. BMC MEDICAL EDUCATION 2023; 23:880. [PMID: 37978527 PMCID: PMC10656937 DOI: 10.1186/s12909-023-04826-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 10/31/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Postgraduate supervision takes place within complex training environments, where experiences are shaped by the socio-cultural context and wider profession, and where tensions permeate. Bordin's working alliance-based model of supervision suggests that quality relationships encompass agreement on the goals and tasks of supervision, in the context of an emotional bond. However, as trainees and their supervisors navigate the demands of providing safe clinical care, alongside educational support, disagreement on expectations for supervision may emerge. By applying a critical lens, this research draws on positioning theory to explore General Practice trainees' experiences of supervision. METHODS In 2017-2019 a series of narrative interviews were undertaken with 13 General Practice trainees in the United Kingdom (UK). Participants were purposively sampled based on end-of-year performance, gender, training location and training status. Interviews were analysed using Brown and Gilligan's Listening Guide, which was adapted to incorporate an exploration of positioning, power and agency. RESULTS Trainees appeared to hold variable positions, such as 'insiders', 'outsiders', 'peers' and 'problem trainees'. Supervisors, through talk and the degree of access afforded, contributed to this positioning. Some trainees viewed their supervisors as brokers and guides as they navigated their training, whilst others were suspicious of the supervisor role. For trainees who raised concerns about their supervisor through formal channels, results were not often satisfactory. Others chose to navigate difficulty in supervision through informal means. This typically involved mastery of artefacts of training, such as the electronic appointment book or training portfolio. CONCLUSIONS This paper builds on Bordin's model of supervision to encourage greater clarity in supervisory discussions, exploring assumptions, and recognising the influences of environment, power, positioning, and agency. We have developed a Model of the Supervisory Alliance in Postgraduate GP Training (MSA-GP) to serve as a springboard for discussion for trainees and their supervisors.
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Affiliation(s)
- Dawn Jackson
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK.
| | - Josephine Brady
- Mary Immaculate College, South Circular Road, Limerick, V94 VN26, Ireland
| | - Donna Dawkins
- School of Education, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
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Torti J, Koppula S, Szafran O, Duerksen K, Barton M. International medical graduates' experiences with caring for cross-cultural patient populations: Qualitative study in Alberta. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2023; 69:557-563. [PMID: 37582601 PMCID: PMC10426355 DOI: 10.46747/cfp.6908557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/17/2023]
Abstract
OBJECTIVE To explore experiences of international medical graduate (IMG) FPs in providing cross-cultural patient care and to identify rewards and challenges they experienced when caring for patients of cultural backgrounds different from their own. DESIGN Descriptive qualitative study. SETTING Family medicine primary care practices in Alberta. PARTICIPANTS Eighteen IMG FPs practising in the metropolitan areas of Edmonton or Calgary in Alberta as of May 2013. METHODS Individual face-to-face or telephone interviews were conducted using a semistructured interview guide. Seventeen interviews occurred between July and August 2013 and 1 took place in August 2014. All interviews were audiorecorded and transcribed verbatim. Transcribed data were subject to thematic analysis. MAIN FINDINGS International medical graduates identified several rewarding aspects of caring for patients with cultural backgrounds different from their own, including learning about different cultures, perceiving that appointments are more succinct, and advocating for patients whom they perceive to be at a disadvantage. Family physicians also identified several challenges associated with caring for patients of different cultural backgrounds, including encountering language barriers, perceiving that visits take longer, and experiencing patients' lack of acceptance of FPs with cultural backgrounds different from their own. CONCLUSION Cultural differences between FPs and patients can enhance or undermine doctor-patient relationships. The results of this study speak to the need for cultural competency training for FPs practising in culturally diverse settings.
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Affiliation(s)
- Jacqueline Torti
- Assistant Professor in the Department of Medicine and Scientist in the Centre for Education Research and Innovation in the Schulich School of Medicine and Dentistry at Western University in London, Ont.
| | - Sudha Koppula
- Associate Professor in the Department of Family Medicine at the University of Alberta in Edmonton
| | - Olga Szafran
- Associate Director of Research in the Department of Family Medicine at the University of Alberta
| | - Kimberley Duerksen
- Research Coordinator in the Department of Family Medicine at the University of Alberta
| | - Martina Barton
- Director of International Medical Graduates in the Department of Family Medicine in the Cumming School of Medicine at the University of Calgary in Alberta
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MacFarlane MM, Pawliuk R, Blew L. Is it really a challenge to find positive attributes for international medical graduates predictive of success in family medicine residency? BMC PRIMARY CARE 2023; 24:147. [PMID: 37452297 PMCID: PMC10347749 DOI: 10.1186/s12875-023-02105-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 07/06/2023] [Indexed: 07/18/2023]
Abstract
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.
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Affiliation(s)
- Malcolm M MacFarlane
- Society for Canadians Studying Medicine Abroad (SOCASMA), 22879-29B Avenue, Langley, BC, V2Z 3B1, Canada.
| | - Rosemary Pawliuk
- Society for Canadians Studying Medicine Abroad (SOCASMA), 22879-29B Avenue, Langley, BC, V2Z 3B1, Canada
| | - Laura Blew
- Society for Canadians Studying Medicine Abroad (SOCASMA), 22879-29B Avenue, Langley, BC, V2Z 3B1, Canada
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Mannes MM, Thornley DJ, Wilkinson TJ. The consequences of cultural difference: the international medical graduate journey in New Zealand. INTERNATIONAL JOURNAL OF MEDICAL EDUCATION 2023; 14:43-54. [PMID: 37141268 PMCID: PMC10693953 DOI: 10.5116/ijme.6440.0e37] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 04/19/2023] [Indexed: 05/05/2023]
Abstract
Objectives To identify how differences in cultural and professional values between New Zealand born and trained doctors and International Medical Graduates (IMGs) affect the practice and retention of IMGs in New Zealand. Methods A mixed-method approach was used. An anonymous 42-item online questionnaire was used to compare participants' cultural and professional values. Participants were 373 New Zealand doctors, 198 IMG, and 25 doctors born and raised elsewhere but who qualified in New Zealand, a group not identified prospectively. The qualitative component used interviews with 14 IMGs to identify cultural challenges faced and with nine New Zealand doctors to identify the challenges they faced working alongside IMGs. Qualitative data were transcribed and analysed thematically. Results There were differences in power distance, with the medically qualified in New Zealand doctors having the highest power distance, followed by the IMGs, suggesting a preference for a hierarchical environment at odds with the New Zealand culture. Interviews found cultural differences in communication styles and hierarchy contributed to professional challenges. The cultural transition was difficult for IMGs as they received minimal support. One-third of IMGs acknowledged their behaviours did not fit well in New Zealand. Complaints about IMGs increased when they reverted to default behaviours regarded negatively by New Zealand colleagues or patients. Conclusions IMGs are open to change but face a lack of orientation and cultural education opportunities, hindering integration. Residency programs must recognise this disconnect and incorporate cross-cultural programmes in the curriculum. Such programmes would assist the adaption and retention of IMG doctors.
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Affiliation(s)
- Mariska M. Mannes
- School of Social Sciences, Media, Film and Communication, University of Otago Dunedin, New Zealand
| | - Davinia J. Thornley
- School of Social Sciences, Media, Film and Communication, University of Otago Dunedin, New Zealand
| | - Tim J. Wilkinson
- Department of Medicine, University of Otago Christchurch, New Zealand
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Elnajjar A, Khan M, Foongsathaporn C, Lu F, Madaan V. Non-US International Medical Graduates in Psychiatry Training During the COVID-19 Pandemic: Challenges and Novel Solutions. ACADEMIC PSYCHIATRY : THE JOURNAL OF THE AMERICAN ASSOCIATION OF DIRECTORS OF PSYCHIATRIC RESIDENCY TRAINING AND THE ASSOCIATION FOR ACADEMIC PSYCHIATRY 2023; 47:205-210. [PMID: 35359249 PMCID: PMC8970639 DOI: 10.1007/s40596-022-01621-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 03/07/2022] [Indexed: 05/25/2023]
Affiliation(s)
| | - Manal Khan
- University of California Los Angeles Medical Center, Los Angeles, CA, USA
| | | | - Francis Lu
- University of California, Davis, Sacramento, CA, USA
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Wiener JC, Rodrigues R, Reid JNS, Archie S, Booth RG, Cheng C, Jan SH, Kurdyak P, MacDougall AG, Palaniyappan L, Ryan BL, Anderson KK. Patient and Physician Factors Associated with First Diagnosis of Non-affective Psychotic Disorder in Primary Care. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2023; 50:212-224. [PMID: 36403173 DOI: 10.1007/s10488-022-01233-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2022] [Indexed: 11/21/2022]
Abstract
Primary care physicians play a central role in pathways to care for first-episode psychosis, and their increased involvement in early detection could improve service-related outcomes. The aim of this study was to estimate the proportion of psychosis first diagnosed in primary care, and identify associated patient and physician factors. We used linked health administrative data to construct a retrospective cohort of people aged 14-35 years with a first diagnosis of non-affective psychosis in Ontario, Canada between 2005-2015. We restricted the sample to patients with help-seeking contacts for mental health reasons in primary care in the six months prior to first diagnosis of psychotic disorder. We used modified Poisson regression models to examine patient and physician factors associated with a first diagnosis of psychosis in primary care. Among people with early psychosis (n = 39,449), 63% had help-seeking contacts in primary care within six months prior to first diagnosis. Of those patients, 47% were diagnosed in primary care and 53% in secondary/tertiary care. Patients factors associated with lower likelihood of diagnosis in primary care included male sex, younger age, immigrant status, and comorbid psychosocial conditions. Physician factors associated with lower likelihood of diagnosis in primary care included solo practice model, urban practice setting, international medical education, and longer time since graduation. Our findings indicate that primary care is an important contact for help-seeking and diagnosis for a large proportion of people with early psychosis. For physicians less likely to diagnose psychosis in primary care, targeted resources and interventions could be provided to support them in caring for patients with early psychosis.
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Affiliation(s)
- Joshua C Wiener
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada. .,Western Centre for Public Health and Family Medicine, 1465 Richmond Street, London, ON, N6G 2M1, Canada.
| | - Rebecca Rodrigues
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | | | - Suzanne Archie
- Department of Psychiatry & Behavioural Neurosciences, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Richard G Booth
- Arthur Labatt Family School of Nursing, Faculty of Health Sciences, Western University, London, ON, Canada
| | - Chiachen Cheng
- Northern Ontario School of Medicine, Thunder Bay, ON, Canada
| | - Saadia Hameed Jan
- Department of Family Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Paul Kurdyak
- ICES, Toronto, ON, Canada.,Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Arlene G MacDougall
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada.,Department of Psychiatry, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada.,Lawson Health Research Institute, London, ON, Canada
| | - Lena Palaniyappan
- Department of Psychiatry, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada.,Lawson Health Research Institute, London, ON, Canada.,Robarts Research Institute, Western University, London, ON, Canada
| | - Bridget L Ryan
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada.,Department of Family Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Kelly K Anderson
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada.,ICES, Toronto, ON, Canada.,Department of Psychiatry, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
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Khoujah D, Ibrahim A. Exploring Teamwork Challenges Perceived by International Medical Graduates in Emergency Medicine Residency. West J Emerg Med 2023; 24:50-58. [PMID: 36735007 PMCID: PMC9897247 DOI: 10.5811/westjem.2022.11.58002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 11/20/2022] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION Non-US international medical graduates (IMG) represent a gradually increasing portion of emergency medicine (EM) residents in the United States. Yet there are no previous studies that explore the needs of this learner population. We conducted a qualitative study to examine non-US IMGs' perceptions of challenges they face specifically regarding team dynamics during their first year of an EM residency. METHOD Nine non-US IMGs in EM from all over the US participated in anonymous, semi-structured phone interviews lasting 45-60 minutes. We then coded and analyzed the interviews to identify axes and themes using an inductive approach informed by grounded theory. Focused coding and member checking were employed. RESULTS Non-US IMGs' perceptions of challenges regarding team dynamics during their first year of an EM residency coalesced into two themes: system-based challenges, such as a new power dynamic and understanding the local hospital system, and interpersonal challenges, such as establishing rapport and articulation of critical thinking. CONCLUSION Non-US IMGs perceived several unique challenges regarding team dynamics during their first year of an EM residency, whether system-based or interpersonal-based. We propose solutions such as a transitional curriculum (as suggested by the participants as well) and cultural-competence training for academic leadership.
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Affiliation(s)
- Danya Khoujah
- Tampa AdventHealth, Emergency Medicine, Tampa, Florida,University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
| | - Ahmed Ibrahim
- Johns Hopkins University, School of Education, Baltimore, Maryland
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Hosseinzadeh H, Ratan ZA, Shnaigat M, Edwards J, Verma I, Niknami M, Dadich A. Effectiveness of case scenario-based teaching to transition international Master of Public Health students specialising in health promotion from memorization to critical thinking. Health Promot J Austr 2022; 33 Suppl 1:39-49. [PMID: 35714044 PMCID: PMC9796551 DOI: 10.1002/hpja.631] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 06/14/2022] [Accepted: 06/14/2022] [Indexed: 01/01/2023] Open
Abstract
ISSUE ADDRESSED Critical thinking is essential to health promotion to overcome increasingly complex health issues. International students from Middle East and Asia are however disadvantaged when required to demonstrate critical thinking mainly because of their previous training in memorisation. This study addresses this need by evaluating the effect of case scenario-based teaching on transition from memorisation to critical thinking among international students in an Australia university. METHODS This was a pre and post intervention study and data were collected from a convenience sample of 79 international Master of Public Health students specialising in health promotion in 2019 at the University of Wollongong. RESULTS Most of the participants were female (73.4%) and aged 25 years or older (64.6%), predominantly from India (40.5%), Nepal (31.6%) and Saudi Arabia (11.4%). A paired t-test analysis showed that the intervention - case scenario-based teaching - significantly improved the mean post-intervention critical thinking skills (P < 0.001). Case studies improved critical thinking among international students, irrespective of demographic attributes. Multiple regression analyses indicated that critical thinking predicted 78.6 of the total marks, after controlling for demographic attributes. In terms of assessment marks, improved multiple solutions skills yielded better marks for tutorial participations; while improved problem identification skills improved marks for report assessments and exams. Improved communication skills led to better marks for essay assessments. CONCLUSIONS Case studies improved critical thinking and was a reliable predictor of student performance among the participants. SO WHAT?: This study makes a strong case for case scenario-based teaching to improve critical thinking among international students. However, given the limitations of this study, including the small, non-representative sample, further testing is required.
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Affiliation(s)
- Hassan Hosseinzadeh
- School of Health and Society, The University of Wollongong (UOW)WollongongNSWAustralia
| | - Zubair Ahmed Ratan
- School of Health and Society, The University of Wollongong (UOW)WollongongNSWAustralia
| | - Mahmmoud Shnaigat
- School of Health and Society, The University of Wollongong (UOW)WollongongNSWAustralia
| | - Joseph Edwards
- School of Health and Society, The University of Wollongong (UOW)WollongongNSWAustralia
| | - Iksheta Verma
- School of Health and Society, The University of Wollongong (UOW)WollongongNSWAustralia
| | | | - Ann Dadich
- School of BusinessWestern Sydney UniversityPenrithNSWAustralia
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Violato E, Witschen B, Violato E, King S. A behavioural study of obedience in health professional students. ADVANCES IN HEALTH SCIENCES EDUCATION : THEORY AND PRACTICE 2022; 27:293-321. [PMID: 34807358 PMCID: PMC9117351 DOI: 10.1007/s10459-021-10085-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 11/14/2021] [Indexed: 06/13/2023]
Abstract
Interprofessional Education and Collaborative Practice (IPECP) is a field of study suggested to improve team functioning and patient safety. However, even interprofessional teams are susceptible to group pressures which may inhibit speaking up (positive deviance). Obedience is one group pressure that can inhibit positive deviance leading to negative patient outcomes. To examine the influence of obedience to authority in an interprofessional setting, an experimental simulated clinical scenario was conducted with Respiratory Therapy (RT) (n = 40) and Advanced Care Paramedic (ACP) (n = 20) students. In an airway management scenario, it was necessary for students to challenge an authority, a senior anesthesiologist, to prevent patient harm. In a 2 × 2 design cognitive load and an interventional writing task designed to increase positive deviance were tested. The effect of individual characteristics, including Moral Foundations, and displacement of responsibility were also examined. There was a significant effect for profession and cognitive load: RT students demonstrated lower levels of positive deviance in the low cognitive load scenario than students in other conditions. The writing task did not have a significant effect on RT or ACP students' behaviour. The influence of Moral Foundations differed from expectations, In Group Loyalty was selected as a negative predictor of positive deviance while Respect for Authority was not. Displacement of responsibility was influential for some participants thought not for all. Other individual variables were identified for further investigation. Observational analysis of the simulation videos was conducted to obtain further insight into student behaviour in a compliance scenario. Individual differences, including experience, should be considered when providing education and training for positive deviance. Simulation provides an ideal setting to use compliance scenarios to train for positive deviance and for experimentation to study interprofessional team behaviour.
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Affiliation(s)
- Efrem Violato
- Department of Educational Psychology, Faculty of Education, University of Alberta, Education North, 11210 - 87 Ave, Edmonton, AB, T6G 2G5, Canada.
| | - Brian Witschen
- School of Health and Life Sciences, Northern Alberta Institute of Technology, Edmonton, Canada
| | - Emilio Violato
- Department of Psychology, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Sharla King
- Department of Educational Psychology, Faculty of Education, University of Alberta, Education North, 11210 - 87 Ave, Edmonton, AB, T6G 2G5, Canada
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Prentice S, Benson J, Dorstyn D, Elliott T. Wellbeing Conceptualizations in Family Medicine Trainees: A Hermeneutic Review. TEACHING AND LEARNING IN MEDICINE 2022; 34:60-68. [PMID: 34126815 DOI: 10.1080/10401334.2021.1919519] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
PHENOMENON High levels of burnout have been widely reported among postgraduate medical trainees, however relatively little literature has examined what 'wellbeing' means for this group. Moreover, the literature that does exist has generally overlooked the potential role of specialty factors in influencing such conceptualizations. This is particularly true for family medicine and general practice trainees - a specialty considered to be unique due, in part, to its focus on community-based care. The present review sought to explore conceptualizations of wellbeing specifically within the context of family medicine and general practice training. APPROACH The Embase, Ovid Medline, and PsycINFO databases were searched from inception to November 2019 for literature examining wellbeing in family medicine and general practice trainees. Literature was iteratively thematically analyzed through the process of a hermeneutic cycle. In total, 36 articles were reviewed over seven rounds, at which point saturation was reached. FINDINGS The findings confirm the complex and multifaceted nature of wellbeing as experienced by family medicine and general practice trainees. An emphasis on psychological factors - including emotional intelligence, positive mental health, self-confidence and resilience - alongside positive interpersonal relationships, rewards, and balanced interactions between trainees' personal and professional demands were deemed critical elements. INSIGHTS A model of wellbeing that emphasizes rich connections between trainees' personal and professional life domains is proposed. Further qualitative research will help to extend current understanding of wellbeing among medical trainees, including the individuality of each specialty's experiences, with the potential to enhance interventional efforts.
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Affiliation(s)
- Shaun Prentice
- School of Psychology, University of Adelaide, Adelaide, South Australia, Australia
| | - Jill Benson
- School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
- GPEx Ltd, Adelaide, South Australia, Australia
| | - Diana Dorstyn
- School of Psychology, University of Adelaide, Adelaide, South Australia, Australia
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MacFarlane MM. When a Canadian is not a Canadian: marginalization of IMGs in the CaRMS match. CANADIAN MEDICAL EDUCATION JOURNAL 2021; 12:132-140. [PMID: 34567315 PMCID: PMC8463232 DOI: 10.36834/cmej.71790] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
This paper explores the marginalization experienced by International Medical Graduates (IMGs) in the Canadian Residency Matching Service (CaRMS) Match. This marginalization occurs despite all IMGs being Canadian citizens or permanent residents, and having objectively demonstrated competence equivalent to that expected of a graduate of a Canadian medical School through examinations such as the MCCQE1 and the National Assessment Collaboration OSCE. This paper explores how the current CaRMS Match works, evidence of marginalization, and ethnicity and human rights implications of the current CaRMS system. A brief history of post graduate medical education and the residency selection process is provided along with a brief legal analysis of authority for making CaRMS eligibility decisions. Current CaRMS practices are situated in the context of Provincial fairness legislation, and rationalizations and rationales for the current CaRMS system are explored. The paper examines objective indicators of IMG competence, as well as relevant legislation regarding international credential recognition and labour mobility. The issues are placed in the context of current immigration and education policies and best practices. An international perspective is provided through comparison with the United States National Residency Matching Program. Suggestions are offered for changes to the current CaRMS system to bring the process more in line with legislation and current Canadian value systems, such that "A Canadian is a Canadian."
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Affiliation(s)
- Malcolm M MacFarlane
- Society for Canadians Studying Medicine Abroad (volunteer), British Columbia, Canada
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Al-Mohawes H, Amante M, Hannon B, Zimmermann C, Kaya E, Al-Awamer A. Online Bridging Program for new international palliative medicine fellows: development and evaluation. BMJ Support Palliat Care 2021:bmjspcare-2020-002797. [PMID: 33737288 DOI: 10.1136/bmjspcare-2020-002797] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 02/11/2021] [Accepted: 03/01/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVES International medical graduates (IMGs) who pursue additional training in another country may encounter unique challenges that compromise their learning experience. This paper describes the development of an Online Bridging Program in the Division of Palliative Care at the University Health Network Toronto and examines its effectiveness in improving IMGs' readiness for Canadian fellowship training. METHODS The annual Online Bridging Program was developed to help new IMGs transitioning to Canadian palliative fellowship using Kern's framework for curriculum development. Following a needs assessment, eight online modules with weekly live sessions were developed and underwent external content validation and usability tests. After each iteration, the programme was improved based on participant feedback. Evaluation was conducted first through an online survey immediately on completion of the programme and then through qualitative interviews 6 months into the fellowship. The interviews were analysed using Braun and Clarke's model for thematic analysis. RESULTS Nine IMGs participated in the Online Bridging Program from 2018 to 2020. All nine participated in the survey and eight in the interviews. Responses to the online survey were almost unanimously positive, suggesting its effectiveness in assisting the IMGs' transitions into fellowship. The interviews revealed four major themes: the importance of combining online modules and live sessions, reducing the fellows' anxiety and easing the transition into their new role, an improved overall learning experience and recognising online format limitations. CONCLUSION The Online Bridging Program effectively eased IMG palliative medicine fellows' transition into training and enhanced their learning experience.
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Affiliation(s)
- Hanan Al-Mohawes
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Madelaine Amante
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Breffni Hannon
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ebru Kaya
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ahmed Al-Awamer
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Zawawi AN, Al-Rashed AM. The experiences of foreign doctors in Saudi Arabia: A qualitative study of the challenges and retention motives. Heliyon 2020; 6:e03901. [PMID: 32885060 PMCID: PMC7453119 DOI: 10.1016/j.heliyon.2020.e03901] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 12/29/2019] [Accepted: 04/23/2020] [Indexed: 11/29/2022] Open
Abstract
Background The Saudi healthcare system is mainly staffed by foreign doctors who constitute about 73% of the total medical workforce. But, the high rate of turnover among these foreigners had deposited an additional unbearable cost and threatens the stability of the provided healthcare services in the country. Objectives This study was conducted to explore the professional and personal challenges that were experienced by foreign medical doctors while working in one of the major governmental tertiary-care hospitals in Riyadh city. The study also seeks to explore the factors that could influence or motivate their retention. Methods A qualitative study based on semi-structured interviews was conducted on January 2018. A total of 16 foreign doctors were recruited purposefully using a maximum variation sampling strategy. The interviews were recorded, transcribed verbatim, and analyzed using thematic analysis technique. Results Three primary themes have been emerged based on the data analysis: (1) Work-related challenges such as; communication and discrimination challenges. (2) Living-related challenges such as; supportive services and restricted movement challenges. (3) Factor motivating retention such as providing good children education, offering flexible traveling regulations, and providing professional development opportunities. Conclusions The findings of this study have indicated that there are more important motivators than money for improving the retention of foreign doctors in the country. Several policy actions have been recommended to maintain their essential role. For example; implementing an ethical code to protect them from receiving deceptive hiring information, developing a specialized pocket dictionary to overcome language barriers, embracing "workforce diversity management" techniques to minimize discrimination at institutional level, and finally it is also recommended to include the foreign doctors' family needs and other living related challenges in any future retention strategies.
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Affiliation(s)
- Amal N Zawawi
- Department of Health Administration, King Saud University, Riyadh, Saudi Arabia
| | - Abeer M Al-Rashed
- Department of Health Administration, King Saud University, Riyadh, Saudi Arabia
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Heist BS, Torok HM. Japanese International Medical Graduates and the United States clinical training experience: Challenges abroad and methods to overcome them. J Gen Fam Med 2020; 21:109-118. [PMID: 32742899 PMCID: PMC7388660 DOI: 10.1002/jgf2.315] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 02/28/2020] [Accepted: 03/03/2020] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Due to the large language and cultural distances between Japan and the US compared to many countries, Japanese International Medical Graduates (IMGs) may have a different US training experience, including more stress, than many IMGs. We examined the US clinical training experience for Japanese IMGs, including the challenges encountered, how those challenges are overcome, and the benefits of US training. METHODS We performed individual semistructured interviews with 35 purposively sampled Japanese IMGs who had completed US clinical training. Exploratory thematic analysis was conducted using iterative data collection and constant comparison. RESULTS All participants reported high personal growth and that US clinical training was worth the sacrifices. Commonly fatigue was lower than during Japanese residency. Participants explained medical practice and local culture associated challenges that aligned with literature on US graduates and other IMGs. By contrast, nearly all participants reported that English communication was very challenging, and described specific language related struggles and methods to help overcome them. Communication struggles were contextualized within an American training culture that values verbal assertiveness. Self-esteem varied among participants and, for some participants, improved with confidence in communication. Several participants reported depression and other mental illness. The training environment varied among residency programs. CONCLUSIONS Japanese IMGs who completed US training report that it was worth it, but describe significant language and culture related struggles and effects on mental health. Further research should address which Japanese IMGs are most likely to struggle, how this will transpire, and how to optimize the US clinical training experience.
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Affiliation(s)
- Brian S. Heist
- Department of MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvania
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18
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Kawaguchi A, Guerra GG, Gilad E, Jain P, DeCaen A. Remote triage in paediatric critical care: A Canadian provincial-wide cohort study. Paediatr Child Health 2020; 26:166-172. [PMID: 33936336 DOI: 10.1093/pch/pxaa036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 02/03/2020] [Indexed: 11/13/2022] Open
Abstract
Objective To describe remote triage of 'potentially' critically ill or injured children in a western Canadian province and to examine the associated factors with 'missings' in vital sign items recorded in centralized telephone triage consultations. Methods This is a provincial-wide prospective cohort study. We included all children under 17 years of age consulted through the central transport coordination centres in Alberta from June 2016 to July 2017. We labeled a value as 'missing' when the actual value was not identified in the audio records. Results In total, 429 cases were included in this study. The median duration of triage calls was 6.8 minutes. Although the patients' demographics and primary diagnoses were similar, backgrounds of the referring physicians and hospitals were significantly different between the two cohorts (i.e., patients referred to Calgary versus Edmonton). The proportion of 'missings' among the vital sign items varied significantly, in which capillary refilling time (60%), pupils (86%), Glasgow Coma Scale (GCS) (79%), and level of respiratory effort (50%) were not well recorded, whereas heart rate (proportion of 'missings': 12%), SpO2 (20%), and respiratory rate (26%) were recorded reasonably well. The lower proportion of 'missings' was observed in older aged patients for several vital sign items including systolic blood pressure and GCS. Conclusions The proportion of missing vital signs recorded varied significantly. The 'missings' could be associated with referring physician's background and patients' demographics such as 'age' that should be considered for the improvement of triage quality in the future.
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Affiliation(s)
- Atsushi Kawaguchi
- Department of Pediatrics, University of Montreal CHU Sainte-Justine, Montreal, Quebec.,Department of Pediatrics, University of Ottawa Children's Hospital Eastern Ontario, Ottawa, Ontario
| | - Gonzalo Garcia Guerra
- Department of Pediatrics, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta
| | - Eli Gilad
- Department of Pediatrics, University of Calgary, Alberta Children's Hospital, Calgary, Alberta
| | - Praveen Jain
- Department of Emergency Medicine, University of Alberta, Edmonton, Alberta
| | - Allan DeCaen
- Department of Pediatrics, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta
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Lui JK, Walsh KF, Philbin M. Strategies for effective intern orientation. CLINICAL TEACHER 2020; 17:600-605. [PMID: 32176457 DOI: 10.1111/tct.13151] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Justin K Lui
- Section of Pulmonary, Allergy, Sleep and Critical Care Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Kathleen F Walsh
- Center for Global Health, Weill Cornell Medicine, New York City, New York, USA
| | - Mary Philbin
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA
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Ashing KT, Dawkins-Moultin L, George M, Antoine GM, Nunez-Smith M, Pérez-Stable EJ. Across borders: thoughts and considerations about cultural preservation among immigrant clinicians. Int J Qual Health Care 2019; 31:G103-G105. [PMID: 30649356 PMCID: PMC7291808 DOI: 10.1093/intqhc/mzy256] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 11/08/2018] [Accepted: 12/24/2018] [Indexed: 11/12/2022] Open
Abstract
Immigrant clinicians make up 20-28% of the health workforce in many high-income countries, including Australia, Britain, Canada and the USA. Yet, the preserved culture of immigrant clinicians remains largely invisible in the medical literature and discourse. Research on immigrant clinicians primarily attends to medical professional requirements for the adopted country (medical board examination eligibility, fellowship training and licensing). Cultural preservation among immigrant clinicians has not been adequately considered or studied. This paper highlights this notable gap in healthcare delivery and health services research relevant to immigrant clinicians. We propose it is worthwhile to explore possible relationships between immigrant clinicians' preserved culture and clinical practices and outcomes since immigrant clinicians cross borders with their academic training as well as their culture. The sparse literature regarding immigrant clinicians suggests culture influences health beliefs, attitudes about the meaning of illness and clinical practice decisions. Additionally, immigrant clinicians are more likely to serve rural, low-income populations; communities with high density of ethnic minorities and immigrants; and areas with primary care shortage. Therefore, cultural preservation among immigrant clinicians may have important implications for public health and health disparities. This area of inquiry is important, if not urgent, in health services research.
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Affiliation(s)
- Kimlin Tam Ashing
- City of Hope Beckman Research Institute—Division of Health Equities, 1500 E Duarte Rd, Duarte, CA, USA
| | - Lenna Dawkins-Moultin
- City of Hope Beckman Research Institute—Division of Health Equities, 1500 E Duarte Rd, Duarte, CA, USA
| | - Marshalee George
- Johns Hopkins University School of Medicine—Division of Surgical Oncology, 733 N Broadway, Baltimore, MD, USA
| | - Gerard M Antoine
- Caribbean Medical Providers Practicing Abroad (CMPPA), Kailua, Hawaii, USA
| | - Marcella Nunez-Smith
- Yale School of Medicine—Department of Internal Medicine, 333 Cedar Street, New Haven, CT, USA
| | - Eliseo J Pérez-Stable
- National Institute on Minority Health and Health Disparities, National Institutes of Health, 6707 Democracy Boulevard, Suite 800, Bethesda, MD, USA
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Jackson D, Davison I, Adams R, Edordu A, Picton A. A systematic review of supervisory relationships in general practitioner training. MEDICAL EDUCATION 2019; 53:874-885. [PMID: 31074063 DOI: 10.1111/medu.13897] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 02/22/2019] [Accepted: 03/20/2019] [Indexed: 05/14/2023]
Abstract
OBJECTIVES The educational alliance is argued to be at the heart of supervision in medical education. This review aims to map the research field and develop a conceptualisation of the nature of such educational alliances within postgraduate supervision for general practitioners. METHODS An integrative review of the international literature on supervision from 2011 to 2018 was undertaken, and papers assessed for relevance and quality. Data analysis incorporated framework analysis techniques. Bordin's working alliance-based model of supervision was used as a springboard for synthesis, as well as allowing for the emergence of new ideas, theories and concepts from the literature. RESULTS A total of 49 full texts were included for analysis. There was evidence of the importance of trust, agreement and bond in accordance with Bordin's model. The results also highlighted the importance of greater clarity on supervisory goals, and the tasks to support these goals, to effectively address competing priorities and roles within supervision. Non-hierarchical relationships were advocated, although supervisors must remain impartial in their assessment and monitoring roles. The influence of the wider practice community and situated learning through legitimate peripheral participation are documented. A model of General practice (GP) supervision is proposed that integrates the findings. CONCLUSIONS GP supervision requires a greater emphasis than is suggested by the working alliance model, both on the clarity of expectations and the appreciation of the multiple roles and competing priorities of both trainee and supervisor. Furthermore, as GP supervision develops within the rising workload of contemporary general practice, the role of the wider community of practice may become more prominent. We have adapted the working alliance model for postgraduate General practice (GP) supervision, emphasising the explicit sharing of expectations relating to goals, tasks and roles to facilitate negotiation and agreement.
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Affiliation(s)
- Dawn Jackson
- Medical School, University of Birmingham, Birmingham, UK
| | - Ian Davison
- School of Education, University of Birmingham, Birmingham, UK
| | - Rachel Adams
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Adaeze Edordu
- Primary Care and Health Sciences, University of Keele, Keele, UK
| | - Aled Picton
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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Wilson DM, Triscott JAC, Cohen J, MacLeod R. Educational needs of healthcare professionals and members of the general public in Alberta Canada, 2 years after the implementation of medical assistance in dying. HEALTH & SOCIAL CARE IN THE COMMUNITY 2019; 27:1295-1302. [PMID: 31149763 DOI: 10.1111/hsc.12766] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 04/29/2019] [Accepted: 05/02/2019] [Indexed: 06/09/2023]
Abstract
Medical assistance in dying (MAID) was implemented across Canada in June of 2016, after each Canadian province and territory had developed their own MAID processes. Over the first 2 years, just under 300 Alberta citizens received MAID services, a very small proportion (<0.5%) of all 52,000 decedents. An online 2017-2018 survey of Alberta healthcare providers and members of the general public was conducted to assess and compare their knowledge of MAID. A devised brief survey tool was posted online, with broad-based advertising for voluntary participants. The survey was taken down after 282 Albertans had participated (100+ healthcare professionals and 100+ members of the general public), a non-representative sample. Through SPSS data analysis, educational needs were clearly evident as only 30.5% knew the correct approximate number of MAID deaths to date, 33.0% correctly identified the point in life when MAID can be done, 48.9% correctly identified the locations where MAID can be performed, 49.3% correctly identified who can stop MAID from being carried out, and 52.8% correctly identified how MAID is performed to end life. Healthcare professionals were significantly more often correct; as were participants born in Canada, university degree holders, working persons, those who identified a religion, had experience with death and dying care, had direct prior experience with death hastening, thought adults had a right to request and receive MAID, had past experience with animal euthanasia, and had hospice/palliative education or work experience. Age, gender, and having previously worked or lived in a country where assisted suicide or euthanasia was performed were not significant for educational needs. These findings indicate new approaches to meet sudden assisted suicide educational needs are needed.
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Affiliation(s)
- Donna M Wilson
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
- Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Jean A C Triscott
- Department of Family Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Joachim Cohen
- End-of-Life Care Research Group, Vrije University Brussels (VUB) and Ghent University, Brussels, Belgium
| | - Rod MacLeod
- Sydney Medical School (Northern) University of Sydney, Sydney, Australia
- HammondCare, Sydney, Australia
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Wearne SM, Brown JB, Kirby C, Snadden D. International medical graduates and general practice training: How do educational leaders facilitate the transition from new migrant to local family doctor? MEDICAL TEACHER 2019; 41:1065-1072. [PMID: 31215285 DOI: 10.1080/0142159x.2019.1616681] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
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.
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Affiliation(s)
- Susan M Wearne
- Academic Unit of General Practice, Australian National University , Canberra , Australia
| | - James B Brown
- Eastern Victoria General Practice Training , Churchill , Australia
| | - Catherine Kirby
- Eastern Victoria General Practice Training , Churchill , Australia
| | - David Snadden
- Northern Medical Program, University of British Columbia , British Columbia , Canada
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Wilbur K, BenSmail N, Ahkter S. Student feedback experiences in a cross-border medical education curriculum. INTERNATIONAL JOURNAL OF MEDICAL EDUCATION 2019; 10:98-105. [PMID: 31129658 PMCID: PMC6766385 DOI: 10.5116/ijme.5ce1.149f] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 05/19/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVES To determine non-Western situated health professional student experiences and preferences for feedback in workplace-based settings. METHODS We conducted five focus groups with 27 students of Arab-origin enrolled in a Canadian-accredited cross-border pharmacy program in Qatar. Transcripts of recorded discussions were analyzed using the framework method. Hofstede's and Hall's cultural dimension models were employed to understand described feedback encounters and behaviours. RESULTS We identified three themes associated with cultural influences on student feedback experiences, namely: 1) collectivism; 2) power distance; and 3) context. Trainees described clinical supervisors who inadequately recognized individual performance, rejected critique, and insufficiently documented feedback onto the written in-training evaluation report. Conversely, students expected specific and timely feedback, invited criticism for learning, and desired clear written commentary. CONCLUSIONS Feedback behaviours of clinical supervisors, but not those of trainees, were consistent with local cultural norms as described by Hofstede and Hall. Instead, feedback expectations of pharmacy students in Qatar largely echo those of other trainees enrolled in professional curricula situated outside the Middle East. Principles for optimal feedback in clinical training largely arise from Western perspectives but are not necessarily universal. Our work demonstrates that practices, in part, may be subject to local socio-cultural influences. This is of particular importance in the experiential training component of cross-border medical education programs adopted by overseas institutions. Our findings also further add to the growing body of literature reporting suboptimal feedback in workplace-based learning, reinforcing the need to cultivate more student-centered practices in health professional training globally.
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Affiliation(s)
- Kerry Wilbur
- Faculty of Pharmaceutical Sciences, the University of British Columbia, Vancouver, Canada
| | - Nawal BenSmail
- Clinical Pharmacist, Hamad Medical Corporation, Doha, Qatar
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Najeeb U, Wong B, Hollenberg E, Stroud L, Edwards S, Kuper A. Moving beyond orientations: a multiple case study of the residency experiences of Canadian-born and immigrant international medical graduates. ADVANCES IN HEALTH SCIENCES EDUCATION : THEORY AND PRACTICE 2019; 24:103-123. [PMID: 30259266 DOI: 10.1007/s10459-018-9852-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 09/19/2018] [Indexed: 05/16/2023]
Abstract
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.
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Affiliation(s)
- Umberin Najeeb
- Wilson Centre for Research in Education, Toronto, ON, Canada.
- Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, M4N3M5, ON, Canada.
- Faculty Lead R4 Internal Medicine Program, University of Toronto, Toronto, ON, Canada.
- Faculty Lead IMG/IFT Mentorship Program, University of Toronto, Toronto, ON, Canada.
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
| | - Brian Wong
- Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, M4N3M5, ON, Canada
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Centre of Quality Improvement and Patient Safety, University of Toronto, Toronto, ON, Canada
| | | | - Lynfa Stroud
- Wilson Centre for Research in Education, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, M4N3M5, ON, Canada
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Core Internal Medicine Program, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Susan Edwards
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Urban Family Health Team, St. Joseph Health Centre, Toronto, ON, Canada
- Resident Wellness, Postgraduate Medical Education Office, University of Toronto, Toronto, ON, Canada
| | - Ayelet Kuper
- Wilson Centre for Research in Education, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, M4N3M5, ON, Canada
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Massey College, Toronto, ON, Canada
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Physician-related determinants of medical end-of-life decisions - A mortality follow-back study in Switzerland. PLoS One 2018; 13:e0203960. [PMID: 30235229 PMCID: PMC6147437 DOI: 10.1371/journal.pone.0203960] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 08/30/2018] [Indexed: 12/12/2022] Open
Abstract
Background Medical end-of-life decisions (MELD) and shared decision-making are increasingly important issues for a majority of persons at the end of life. Little is known, however, about the impact of physician characteristics on these practices. We aimed at investigating whether MELDs depend on physician characteristics when controlling for patient characteristics and place of death. Methods and findings Using a random sample (N = 8,963) of all deaths aged 1 year or older registered in Switzerland between 7 August 2013 and 5 February 2014, questionnaires covering MELD details and physicians' demographics, life stance and medical formation were sent to certifying physicians. The response rate was 59.4% (N = 5,328). Determinants of MELDs were analyzed in binary and multinomial logistic regression models. MELDs discussed with the patient or relatives were a secondary outcome. A total of 3,391 non-sudden nor completely unexpected deaths were used, 83% of which were preceded by forgoing treatment(s) and/or intensified alleviation of pain/symptoms intending or taking into account shortening of life. International medical graduates reported forgoing treatment less often, either alone (RRR = 0.30; 95% CI: 0.21–0.41) or combined with the intensified alleviation of pain and symptoms (RRR = 0.44; 0.34–0.55). The latter was also more prevalent among physicians who graduated in 2000 or later (RRR = 1.60; 1.17–2.19). MELDs were generally less frequent among physicians with a religious affiliation. Shared-decision making was analyzed among 2,542 decedents. MELDs were discussed with patient or relatives less frequently when physicians graduated abroad (OR = 0.65, 95% CI: 0.50–0.87) and more frequently when physicians graduated more recently; physician's sex and religion had no impact. Conclusions Physicians' characteristics, including the country of medical education and time since graduation had a significant effect on the likelihood of an MELD and of shared decision-making. These findings call for additional efforts in physicians' education and training concerning end-of-life practices and improved communication skills.
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Klingler C, Ismail F, Marckmann G, Kuehlmeyer K. Medical professionalism of foreign-born and foreign-trained physicians under close scrutiny: A qualitative study with stakeholders in Germany. PLoS One 2018; 13:e0193010. [PMID: 29447259 PMCID: PMC5814013 DOI: 10.1371/journal.pone.0193010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 01/19/2018] [Indexed: 11/22/2022] Open
Abstract
Hospitals in Germany employ increasing numbers of foreign-born and foreign-trained (FB&FT) physicians. Studies have investigated how FB&FT physicians experience their professional integration into the German healthcare system, however, the perspectives of stakeholders working with and shaping the work experiences of FB&FT physicians in German hospitals have so far been neglected. This study explores relevant stakeholders’ opinions and attitudes towards FB&FT physicians—which likely influence how these physicians settle in—and how these opinions were formed. We conducted a qualitative interview study with 25 stakeholders working in hospitals or in health policy development. The interviews were analyzed within a constructivist research paradigm using methods derived from Grounded Theory (situational analysis as well as open, axial and selective coding). We found that stakeholders tended to focus on problems in FB&FT physicians’ work performance. Participants criticized FB&FT physicians’ work for deviating from presumably shared professional standards (skill or knowledge and behavioral standards). The professional standards invoked to justify problem-focused statements comprised the definition of an ideal behavior, attitude or ability and a tolerance range that was adapted in a dynamic process. Behavior falling outside the tolerance range was criticized as unacceptable, requiring action to prevent similar deviations in the future. Furthermore, we derived three strategies (minimization, homogenization and quality management) proposed by participants to manage deviations from assumed professional standards by FB&FT physicians. We critically reflect on the social processes of evaluation and problematization and question the legitimacy of professional standards invoked. We also discuss discriminatory tendencies visible in evaluative statements of some participants as well as in some of the strategies proposed. We suggest it will be key to develop and implement better support strategies for FB&FT physicians while also addressing problematic attitudes within the receiving system to further professional integration.
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Affiliation(s)
- Corinna Klingler
- Institute of Ethics, History and Theory of Medicine, Ludwig-Maximilians-Universität München, Munich, Germany
- * E-mail:
| | - Fatiha Ismail
- Institute of Ethics, History and Theory of Medicine, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Georg Marckmann
- Institute of Ethics, History and Theory of Medicine, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Katja Kuehlmeyer
- Institute of Ethics, History and Theory of Medicine, Ludwig-Maximilians-Universität München, Munich, Germany
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Michalski K, Farhan N, Motschall E, Vach W, Boeker M. Dealing with foreign cultural paradigms: A systematic review on intercultural challenges of international medical graduates. PLoS One 2017; 12:e0181330. [PMID: 28715467 PMCID: PMC5513557 DOI: 10.1371/journal.pone.0181330] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Accepted: 06/29/2017] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- Kerstin Michalski
- Institute for Medical Biometry and Statistics, Faculty of Medicine and Medical Center – University of Freiburg, Freiburg, Germany
| | - Nabeel Farhan
- Freiburg International Academy – University of Freiburg, Freiburg, Germany
| | - Edith Motschall
- Institute for Medical Biometry and Statistics, Faculty of Medicine and Medical Center – University of Freiburg, Freiburg, Germany
| | - Werner Vach
- Institute for Medical Biometry and Statistics, Faculty of Medicine and Medical Center – University of Freiburg, Freiburg, Germany
| | - Martin Boeker
- Institute for Medical Biometry and Statistics, Faculty of Medicine and Medical Center – University of Freiburg, Freiburg, Germany
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Osta AD, Barnes MM, Pessagno R, Schwartz A, Hirshfield LE. Acculturation Needs of Pediatric International Medical Graduates: A Qualitative Study. TEACHING AND LEARNING IN MEDICINE 2017; 29:143-152. [PMID: 28033485 DOI: 10.1080/10401334.2016.1251321] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
UNLABELLED Phenomenon: International medical graduates (IMGs) play a key role in host countries' health systems but face unique challenges, which makes effective, tailored support for IMGs essential. Prior literature describing the acculturation needs of IMGs focused primarily on communication content and style. We conducted a qualitative study to explore acculturation that might be specific to IMG residents who care for children. APPROACH In a study conducted from November 2011 to April 2012, we performed four 90-minute semistructured focus groups with 26 pediatric IMG residents from 12 countries. The focus group transcripts were analyzed using open and focused coding methodology. FINDINGS The focus groups and subsequent analysis demonstrated that pediatric IMG residents' socialization to their home culture impacts their transition to practice in the United States; they must adjust not only to a U.S. culture, different from their own, but also to the culture of medicine in the United States. We identified the following new acculturation themes: understanding the education system and family structure, social determinants of health, communication with African American parents, contraception, physician handoffs, physicians' role in prevention, adolescent health, and physicians' role in child advocacy. We further highlight the acculturation challenges faced by pediatric IMG residents and offer brief recommendations for the creation of a deliberate acculturation curriculum for pediatric IMG residents. Insight: Residency training is a unique period in physicians' personal and professional development and can be particularly challenging for IMGs. There is a significant gap in the identified acculturation needs and the current curricula available to IMG residents who care for children.
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Affiliation(s)
- Amanda D Osta
- a Department of Pediatrics , University of Illinois-Chicago , Chicago , Illinois , USA
- b Department of Internal Medicine , University of Illinois-Chicago , Chicago , Illinois , USA
| | - Michelle M Barnes
- a Department of Pediatrics , University of Illinois-Chicago , Chicago , Illinois , USA
- b Department of Internal Medicine , University of Illinois-Chicago , Chicago , Illinois , USA
| | - Regina Pessagno
- c Department of Sociology , University of Illinois-Chicago , Chicago , Illinois , USA
| | - Alan Schwartz
- d Department of Medical Education , University of Illinois-Chicago , Chicago , Illinois , USA
| | - Laura E Hirshfield
- d Department of Medical Education , University of Illinois-Chicago , Chicago , Illinois , USA
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Wilbur K, Mousa Bacha R, Abdelaziz S. How does culture affect experiential training feedback in exported Canadian health professional curricula? INTERNATIONAL JOURNAL OF MEDICAL EDUCATION 2017; 8:91-98. [PMID: 28315858 PMCID: PMC5376492 DOI: 10.5116/ijme.58ba.7c68] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 03/04/2017] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To explore feedback processes of Western-based health professional student training curricula conducted in an Arab clinical teaching setting. METHODS This qualitative study employed document analysis of in-training evaluation reports (ITERs) used by Canadian nursing, pharmacy, respiratory therapy, paramedic, dental hygiene, and pharmacy technician programs established in Qatar. Six experiential training program coordinators were interviewed between February and May 2016 to explore how national cultural differences are perceived to affect feedback processes between students and clinical supervisors. Interviews were recorded, transcribed, and coded according to a priori cultural themes. RESULTS Document analysis found all programs' ITERs outlined competency items for students to achieve. Clinical supervisors choose a response option corresponding to their judgment of student performance and may provide additional written feedback in spaces provided. Only one program required formal face-to-face feedback exchange between students and clinical supervisors. Experiential training program coordinators identified that no ITER was expressly culturally adapted, although in some instances, modifications were made for differences in scopes of practice between Canada and Qatar. Power distance was recognized by all coordinators who also identified both student and supervisor reluctance to document potentially negative feedback in ITERs. Instances of collectivism were described as more lenient student assessment by clinical supervisors of the same cultural background. Uncertainty avoidance did not appear to impact feedback processes. CONCLUSIONS Our findings suggest that differences in specific cultural dimensions between Qatar and Canada have implications on the feedback process in experiential training which may be addressed through simple measures to accommodate communication preferences.
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Affiliation(s)
- Kerry Wilbur
- College of Pharmacy, Qatar University, Doha, Qatar
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