Supervising International Medical Graduates (IMGs)

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.

Resources

Navigating Medicare

Managing Medicare Billing

Medicare Compliance

Professional and Ethical Practice

Communication Skills Toolbox

VIDEO: How do cultural values and perceptions impact on clinical care?

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

Resources

History taking skills

Writing quality referrals

VIDEO: Australian slang

Australian slang dictionary

Slang terms in the consulting room

Website: Doctors Speak Up

VIDEO: Doctors Speak Up website

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.

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

Health Education, 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

Identifying and Managing Medico-legal Risks

• 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

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).

Resources

Identifying and supporting GP registrars at risk guide

Identifying and supporting GP supervisors in difficulty