Supervising International Medical Graduates (IMGs)

It is well recognised that IMGs face multiple challenges to successful passage through, and completion of, GP training. There has been a call for GP supervisors to better understand and develop strategies to better support IMG GP registrars. This page and associated resources seek to do this.

The two core resources are the Supervising the International Medical Graduate (IMG) guide (right) and Supervising the International Medical Graduate (IMG) webinar video below.

Other useful resources are the IMG assessment tools and the Supervising the IMG FAQs (right). The assessment tools help to identify the registrar’s strengths and weaknesses, and learning needs. The FAQs provides a summary of some of the core issues affecting IMGs.

Supervising the International Medical Graduate (IMG) GP Registrar Guide

This guide is a comprehensive resource for GP supervisors to support IMGs training in their practices.

 

IMG Assessment Tools

IMG Self Assessment tool to identify strengths and opportunities for learning. Supervisor tool with guided questions for IMG registrar to consider following self assessment.

Supervising the IMG FAQs

Contains information on resources, principles of IMG supervision and the top 5 tips when working with IMG registrars.

Principles of IMG Supervision

There are a number of broad principles that should guide the supervision of IMG GP registrars. While these are appropriate to all registrars, they have particular importance for IMGs.

These broad principles are listed below and described more fully in the Supervising the International Medical Graduate (IMG) guide.

  • Avoid generalisations and stereotyping
  • Identify differences, not deficits
  • Expect the need for broad supports
  • Foster a culture of learning and feedback
  • Provide comprehensive orientation
  • Engage assistance early
IMG Principles

Supervising the IMG toolkit

The Supervising the IMG toolkit below is a repository of useful resources and links to help GP supervisors support their IMG registrars.

NOTE: The Supervising the IMG guide is the definitive resource and has significantly more detail than what is listed below

For consultation skill teaching, please also refer to the Consultation skills toolkit and the consultation skills teaching plans.

There are multiple issues related to cultural differences that are challenges for IMGs.  The culture of medicine varies enormously from one country to another. The Australian medical system is likely to be vastly different to that in which the IMG trained, in structure, funding, and complexity. It is important that the supervisor help them to build confidence in working within a new system without feeling overwhelmed. IMG registrars have described the challenges of understanding Australian culture as a significant training issue, including aspects as diverse as dress codes, sexual practices, and alcohol consumption. It has been found that IMGs may at times impose their own cultural norms during a consultation. Conversely, racism and community acceptance have been identified as issues for IMGs. IMGs may also need to develop cultural competence in managing patients from multiple cultural groups, reflecting the diverse multicultural nature of Australia.
Tips Icon


  • Ask your registrar about their previous medical practice. How did they interact with patients? Did they work as part of a team? How did they interact with specialists and other care providers? What was the ‘medical culture’ in their home country?
  • Ask your registrar whether any aspects of the Australian culture are particularly challenging for them in their interaction with patients.
  • Ask your registrar whether they have ever been subjected to racism and how they dealt with it.
  • Ask your registrar to reflect on their own ‘cultural lens’ i.e., their own unique personal worldview influenced by the cultures that nurtured them. How might that impact on the approach to patients from other cultures?

Resources

Navigating Medicare

Managing Medicare Billing

Medicare Compliance

Professional and Ethical Practice

Communication Skills Toolbox
It is well known that some IMG registrars have significant language issues that may impact on satisfactory communication, both with patients and peers. This has clear consequences for clinical outcomes, examination performance and confidence. Most IMGs will have English as their second (or third or fourth!) language, even though they may have been exposed to English as the language of instruction. IMG GPRs may struggle with fluency and structure, and comprehension of colloquial English. IMGs have also specifically identified that understanding Australian slang, idioms and mannerisms can be a challenge. Specific scenarios that require the use of specific communication skills can also be challenging, for example communicating with children, managing the angry patient, saying no, breaking bad news, motivational interviewing, palliative care, and grief counselling. Areas in which IMGs may have problems are:

  • Picking up patient cues (verbal and non-verbal).
  • Demonstrating empathy.
  • Establishing rapport.
  • Appropriately responding to difficult situations
  • Translating medical jargon into lay language.
  • Clarity of written communications
Tips Icon


 

  • Ask your registrar what communication skills training they have done in the past, if any.
  • Employ a broad range of teaching methods to focus on communication skill development e.g. direct observation, role play, random case analysis.
  • Give explicit feedback on communication skill issues, including written English, even though it might be challenging.
  • Demonstrate your ‘spiel’ for explanation and management.
  • Encourage your registrar to use simple communication strategies in the consultation (see diagram 1).
  • Discuss non-verbal cues and their likely meanings in Australian general practice.
  • Discuss and role play situations where specific communication strategies may be required (as above).
  • Encourage reflective practice in your registrar i.e. ‘How well did I communicate in that consultation?’
  • Encourage your registrar to watch local TV shows, read newspapers, see Australian films, attend local venues e.g. sports clubs or RSL (if comfortable) etc. to help refine their everyday English language skills.
  • Consider online learning courses e.g. Doctors Speak Up website13 or assistance from professional linguists/language teachers.
  • Provide useful phrases

Resources

The Communication Toolbox: Overseas Trained Doctors (OTDs)

History taking skills

Writing quality referrals

The pass rate for Fellowship examinations is lower for IMGs, including in those assessments of applied clinical knowledge.  Even where knowledge may be reasonable, it has been observed that the application of clinical knowledge can be an issue for some IMGs. Below are some of the key areas in which IMG registrars may have clinical challenges:

  • History Taking – History taking can be compromised by language barriers, communication issues and cultural differences, such as a biomedical approach to asking questions of patients rather than a dialogue. It may also be culturally unacceptable to take sexual history of  patients of opposite genderor exploring social circumstances like intimate partner violence.
  • Physical Examination – In some cultures, physical examination is less commonly performed, or it may not be appropriate for a male doctor to examine a female (or vice versa). As well, more intimate examinations like a pelvic examination may be deemed culturally unacceptable.
  • Management Planning – This is another potential lacking area of clinical skill development for IMG GPRs. The role of the allied health practitioner might be unfamiliar to many IMGs, reflecting the medical culture and access to resources in which they trained.
  • Investigations – The rational use of investigations may be challenging for IMGs dues to challenges in effective history taking and examination, lack of a patient-centred approach, intolerance of uncertainty, and the influence of past training or clinical practice.
  • Prescribing – Prescribing is another recognised area of clinical skill development for IMG GPRs, with similar factors underpinning it.
Tips Icon


  • Ask your registrar about the nature of their past clinical experience i.e. range of demographics, presentations etc.

  • Help your registrar identify their learning needs and clinical knowledge gaps using appropriate methods e.g. clinical self-assessment tool, random case analysis.

  • Discuss local and national disease epidemiology.

  • Encourage use of appropriate clinical resources and guidelines e.g. RACGP Red Book, Therapeutic Guidelines, Health Pathways.

  • Focus teaching on rational use of tests and treatments.

  • Use the GPSA teaching plans for in-practice teaching on identified knowledge deficits.

Resources

History taking skills

Physical examination skills

Chronic disease management care planning

Rational test ordering

Rational prescribing guide

Registrars often struggle to facilitate an effective, organised, and time-efficient consultation with their patients. This is particularly the case for many IMG registrars, where the primacy of the general practice consultation may not have been a feature of their past training or experience.

Areas such as building the doctor-patient relationship, opening the discussion, understanding the patients perspective, sharing information, reaching agreement and providing closure may be challenging for many IMG registrars. 

Resources

Brief intervention and motivational interviewing

Patient centred care

Follow up and safety netting

 

 

Professional and ethical practice

Professionalism is another area which has been identified as a focus for skill development for IMGs. This includes issues such as setting boundaries, difficulties obtaining consent, reluctance to disclose errors, and interpersonal communication.

Medicolegal

There is evidence that IMGs from some countries have a higher risk of malpractice claims and adverse findings than Australian trained doctors.29 Common themes of ‘at risk’ countries of training include English as a second language, and different medical education and health systems to Australia. Specific areas include opiate prescribing and managing drug seekers (including being able to ‘say no’). For example, some drug seeking patients see IMGs as a ‘soft target’ and will sometimes be aggressive to get their way. Many IMGs may struggle with how to decline prescription requests.

Resources

Teaching professionalism guide

Teaching professionalism FAQ

Professional and ethical practice teaching plan

Professionalism and Role-modelling Resource pack

Identifying and Managing Medico-legal Risks

IMG registrars are known to have lower pass rates in Australian GP training. One of the many potential factors underpinning this relates to the approach to learning. Below are some of the key areas of teaching and learnnig that may be challenging for IMGs.

  • Cultural approaches to learning – Many cultures embrace a strong hierarchy in the educational process, in which the teacher is seen as an expert, rather than a facilitator of knowledge. In such settings, there is often much less emphasis on identification of the learners individual learning needs and self-directed learning. The IMG registrar may be less comfortable speaking up or challenging their teacher.
  • Exam Preparation – IMGs are known to have lower pass rates in postgraduate examinations than local doctors,  likely due to cultural issues, communication and English language skills, clinical skills and study techniques.
  • Oral examinations –  In many settings oral examinations are traditionally examiner led, rather than candidate-led, and IMGs may need to change their approach from passivity and be encouraged to speak confidently about what they know.
  • Feedback – Factors such as perceived power dynamics between teacher and learner, communication issues, attitudes towards critique, and potential vulnerability in evaluation may differ for IMGs. In many cultures, critique is not a usual part of day-today practice and can therefore be misconstrued as evidence of a serious failure, associated with loss of face, shame and embarrassment.
  • Help seeking – It is known that the approach to help seeking varies between cultures and can impact on learning. IMG registrars may not ask for assistance directly, but may instead more subtly ‘hint’ at problems. This may be overlooked or misinterpreted by the supervisor.

Resources

Planning learning

Supporting GP registrars with the AKT and KFP

Preparing GP registrars for StAMPS

Feedback guide

Feedback FAQ

A “Call for Help” List for Supervisors and Registrars

 

Personal issues

For many IMGs, personal stressors are magnified. Migration and displacement may mean the absence of family and community supports. IMGs have described relocation to rural areas as a particularly stressful time, commonly associated with separation from partners and isolation. Family concerns are thus common. IMGs may be subject to prejudice or racism, which understandably can have a major impact on wellbeing. As well, IMG GPRs may have to adapt to a sudden change in status (specialist to trainees).

Tips Icon


  • Get to know the story behind your registrar – their background and life.
  • Let the registrar know that you ‘have their back’ at all times.
  • Encourage participation in community events.
  • Encourage your registrar to have their own GP.

Resources

Identifying and supporting GP registrars at risk guide
Identifying and supporting GP supervisors in difficulty