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.
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.
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
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.
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:
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:
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.
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.
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.
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.
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.
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).