16. International Medical Graduates (IMGs)

Print

Author: Umberin Najeeb, MD, FCPS (Pak), FRCPC

Co-Author: Seyi Akinola,MBChB, MsPH, CCFP

Objectives

After reading this chapter you will be able to:

  • describe the changing landscape of International Medical Graduates
  • discuss perceptions about IMG learners
  • identify the challenges and opportunities experienced by IMG physicians
  • develop an approach to support IMG learners in our training programs

Case scenario

Dr. Tomah is the residency program director for Dr. Jennifer Doe, an IMG. During an eight-week internal medicine rotation at the start of Dr. Doe’s first postgraduate year, her primary supervisor for the fourth to sixth weeks comments to Dr. Sappier that Dr. Doe has excellent book knowledge and she can give an extensive differential diagnosis for any chief complaint during teaching rounds. However, the supervisor has also noticed that Dr. Doe has difficulty applying her knowledge base to actual patient care. She struggles with clinical reasoning and independent generation of care plans for her patients. When the team meets at the end of the day to review patients, she is quiet and does not participate in the discussion unless asked questions directly. The senior resident has also shared with Dr. Tomah his concerns that Dr. Doe takes about one to two hours for a new consult in the emergency department and for her daily SOAP (subjective, objective, assessment and plan) notes; she tends to copy almost verbatim what another resident has written earlier in the day.

Introduction

Nearly 25% of practising physicians in North America received their undergraduate medical education outside of Canada or the United States.1 These types of trainees in Canadian postgraduate training programs fall into three categories:

  • International IMGs (I-IMGs) are physicians who have immigrated to Canada with a medical degree from a World Health Organization (WHO) listed medical school outside Canada or the United States.
  • Canadian IMGs (C-IMGs) are Canadian citizens or permanent residents who have gone abroad (outside Canada or the United States) for their medical education. Canadian studying abroad (CSA) is another term used to describe a learner in this group.
  • Internationally funded trainees (IFTs) or visa trainees are learners from Gulf States whose postgraduate education is sponsored by their country of origin. IFTs apply directly to postgraduate training programs at Canadian medical schools; they do not need to go through the Canadian Resident Matching Service (CaRMS). Learners in this unique group are not considered IMGs.

Both C-IMGs and I-IMGs enter Canadian learning environments with a diversity of life, educational and work experiences. They have studied medicine in educational systems that have differing curricula, resources and patient populations. Part of the mandate of postgraduate medical education in Canada is to ensure that IMGs transition and integrate effectively into residency programs and clinical practice settings.

Changing Landscape of IMGs

Canadian residency application and selection processes are complex. Both C-IMGs and I-IMGs must go through a series of steps before applying for designated IMG residency positions in Canada through CaRMs. Candidates must have completed the Medical Council of Canada Qualifying Examination Part 1 (MCCQE1), the National Assessment Collaboration (NAC) objective structured clinical examination (OSCE) and language proficiency examinations (if they communicated with patients in a language other than English or French during their undergraduate medical training). The recertification and residency matching process require emotional, physical and financial resources.

The degree of competition for the small number of IMG residency position is enormous. In the 2022 R-1 Main Residency Match, only 439 of the 1322 IMG physicians who applied (33%) were successful in securing a residency spot. In contrast, 96% of the Canadian medical school graduates (CMGs) who applied (2844 of 2953) were successfully matched. The total number of available residency positions, the specialties in which they are available and the proportion open to CMGs versus IMGs are determined by provincial and territorial ministries of health, which also fund these positions.

The IMG match rates have been consistent for the last 10 years, with only minor fluctuations; however, C-IMGs have been obtaining an increasing share of the designated IMG residency positions in the past several years. In 2011, C-IMGs represented approximately a quarter of the IMG applicant pool in Canada, but they received about half of the available IMG residency positions in Ontario. The number of IMGs who earned their MD degree in Ireland and completed their postgraduate training in Canada increased by 197% between 2010 and 2018. Similarly, since that period, the numbers of IMG graduates from the United Kingdom and Australia who have matched into Canadian residency programs have increased by 130% and 96%, respectively. The 2020 national IMG data base report produced by the Canadian Post-MD Education Registry (CAPER) indicates that Ireland, the United Kingdom, the United States and Australia continue to be among the top five countries where matched IMG trainees have obtained their MD degree in the last several years. These matching trends raise serious concerns about lack of equity in the selection process for IMGs in Canadian training programs.

Once matched, it is imperative that IMG residents become well integrated into their new training and work environments. Association of Faculties of Medicine of Canada’s mandate postgraduate medical education systems to “ensure the effective integration of IMGs into Canadian residency programs and their transition into practice must be a priority”. A major challenge for I-IMGs is the need to adapt to a new country and its medical system, including such diverse aspects as “differences in disease patterns, levels of technology, treatment options, forms of health care delivery, language, culture, lifestyle, gender roles and, in some ways, status.” I-IMGs enter North American residency training programs through a variety of educational and vocational routes, possessing various levels of English and/or French language skills and a diversity of life experiences. Some I-IMGs have practised medicine before immigrating, while others arrive straight out of medical training. All these factors affect their educational needs.

In contrast, C-IMGs may not need to adapt to the social norms of a new country when they return to Canada, but they face challenges nonetheless. In 2010, the last year for which national data are available, more than 3500 Canadians were studying medicine abroad at 80 medical schools in 30 countries. C-IMGs study in educational systems with widely varying curricula, resources and patient populations. For C-IMGs, the choice of a medical school depends on many personal and financial factors. Those with more financial resources tend to choose medical schools in Australia and Ireland.2 Caribbean medical schools are also very popular because of their geographic proximity to Canada and pre-clerkship rotations based  in US medical schools. In many of these medical schools, students are not given much responsibility; they don’t carry their own patients or do overnight calls. Their role is more like that of a shadow learner, observing a resident or staff physician delivering patient care.

Common Integration CHALLENGES Program should acknowledge and address

The process of adaptation

Wong and colleagues have suggested IMGs must go through three phases of training and practice experiences — loss, disorientation and adaptation — before they can achieve full integration and reach their professional potential in their recipient medical communities.3 IMGs experience loss of their professional identity and status as a physician at an individual level; the sense of loss is more profound in I-IMGs who were practising physicians or subspecialists in their home country. Most interventions described in the literature address early disorientation (usually with dedicated workshops or orientation sessions before or at the beginning of training).4 Most of these early-phase interventions, however, focus on teaching all IMG physicians about communication and cultural issues that may not be relevant to C-IMGs, who are very comfortable with Canadian culture in general.

Attending a one-time orientation program or session is not enough. Both I-IMGs and C-IMGs experience a period of disorientation and transition despite participating in mandatory orientation programs before or at the start of their residencies. This suggests that differences beyond general cultural ones are relevant for IMGs, including differences in the medical system and the knowledge that physicians are expected to have in Canada compared with in the countries where they were trained.1 Najeeb and colleagues suggest that the transition from the disorientation phase to the adaptation phase differs by IMG group: “general cultural adaptation is more relevant to I-IMGs, whereas adaptation to educational and healthcare system is pertinent for both groups.”1 On the other hand, as Canada is a country of uninvited settlers, there have been instances where I-IMGs and C-IMGs have gone to medical school in the same country and have not been all that different in terms of their educational needs. This can further complicate curriculum planning but may positively increase social cohesion between the two groups of IMGs.

Although IMGs make the transition toward adaptation over time as they gain work experience in the Canadian health care system, targeted curricular innovations accelerate this phase for both I-IMGs and C-IMGs. Programs and organizations need to provide ongoing support to both I-IMGs and C-IMGs during their residency to help them transition from the disorientation to the adaptation phase of their experiences. These efforts must be tailored to the needs of the individual resident, but they should also address faculty and training program factors that influence the transition process. Program directors are encouraged to reflect on and draw meaningful connections from both the personal and the programmatic perspective to identify areas of improvement in their program’s selection criteria and identify opportunities to implement further innovations in their programs specifically for IMG learners.

Othering

IMG learners, despite having been accepted into competitive residency programs, perceive that they are treated differently by faculty members and resident colleagues because they carry the label of IMG. I-IMGs feel that they are discriminated against because they are recognizable as a visible minority because of their race, ethnicity, communication style, accent or way of dressing.1 However, C-IMGs also experience the same preception of discrimination because of their  inability to obtain admission into undergraduate medical training at a Canadian medical school and because they may have received their education in a for-profit medical education system. The universal feeling among IMG residents of being “othered” by many of their peers and teachers further contributes to their disorientation and delays the process of integration; it also raises concerns about equity within Canadian training programs. In addition, it points clearly to the need for more faculty development initiatives.1

Return of Service

All Canadian provinces except Quebec and Alberta ask IMG residents to sign return of service (ROS) contracts requiring them to practise medicine in underserviced areas after completing their residency training. The ROS limits the recruitment of IMG faculty at large academic centres (as they are often not in underserviced areas), further reducing IMG voices at residency program leadership tables. This lack of inclusion of IMG faculty in curriculum planning and implementation also impacts the transition and integration of IMG residents. Owing to ROS contracts, there are very few IMG faculty members who can act as role models for IMG trainees.

TIPS every PD should consider: 1,5,6

  1. Continue to innovate and develop both general and specialty-specific orientation programs, ensuring that they focus on the needs of both I-IMGs and C-IMGs.
    • Orientation programs should offer resources to help I-IMGs to adapt to new cultural norms (e.g., dress code, weather changes, communication expectations, housing, childcare and financial support) as needed.
    • Resources to facilitate integration into the new workplace culture should address the needs of both C-IMGs and I-IMGs. Patient autonomy is a hallmark of health care delivery in Canada and should be a focus in orientation programs. Teamwork with allied health care professionals, use of electronic medical records, nuanced goals of care conversations and health care resource availability/allocation are additional themes that can be covered.
    • Consider developing a handbook with important resources and information to clearly set out the expectations of IMGs’ roles and responsibilities as postgraduate learners in your program.
  2. If you don’t already have one, create mentorship programs for IMG residents to provide ongoing support to facilitate their transition, integration and adaptation process. Multiple mentorship models have been developed; a longitudinal collaborative mentorship model with faculty and peer support is one way to provide ongoing support.
    • Matching junior IMG residents with senior IMG residents ideally from the same training program at the start of residency can be a helpful strategy. As peer mentors, senior IMG learners can provide positive role modelling and potentially negate junior IMG learners’ perception that they are being treated differently or “othered,” because their peers are helping them integrate successfully to reach their full learning potential. Seeing senior IMG peers who are progressing successfully also provides junior IMG trainees with emotional and appraisal support.
    • Ideally, the faculty mentor assigned to an IMG trainee should be experienced in training and educating IMGs. However, some residency programs do not have enough IMG faculty members to fulfil this role because, as discussed above, IMGs often have to practise in underserviced areas owing to ROS obligations. If this is the case in your program, one way to mitigate this challenge is to assign a dedicated faculty lead for all of your IMG trainees. This would be an IMG faculty member or a non-IMG faculty member very experienced in working with IMGs who would not be involved in evaluating the IMG trainees’ performance but who could gain their trust because of their prior experience and relatability and could provide them with support in a way that ensures anonymity and confidentiality.
  3. Consider providing educational programs for your residency program’s faculty members. Faculty development programs and initiatives can provide insight to staff preceptors and supervisors about the heterogeneity of IMG learners, the degree of competition in the residency matching process, the diversity of IMGs’ learning needs and ways for teachers to meet specific needs of IMG residents. Najeeb and colleagues suggested that such programs should “incorporate concepts of intersectionality and cultural safety which are normally discussed in the medical education literature in reference to interactions with diverse patient groups rather than with learners.”1 These initiatives will prepare and empower faculty members to foster a safe environment and to supervise IMG trainees in a culturally sensitive, equitable and inclusive manner.
  4. Explore the need for structural changes at the program level to address any systemic and/or individual discrimination perceived by IMGs. These changes may be needed for IMGs to truly feel valued and have a sense of belonging in their residency training programs. IMGs do feel valued if their prior educational and work experiences are acknowledged by their peers, faculty and program leadership. For example, an IMG trained in Asia or Africa will have more experience in managing infectious disease like malaria or tuberculosis than a resident trained in Canada. An appreciative inquiry lens can lessen the sense of loss and disorientation.
  5. Advocate for changes at the provincial and national levels to allow IMG physicians to play an important role in the Canadian health care system. Integrating IMG physicians effectively is fundamental to achieving the right mix, number and distribution of physicians across Canada. This will require concerted action by governments, including immigration authorities, licensing authorities, universities and health systems.
    • If your province does not have ROS requirements, encourage the retention of IMGs who graduate from your program as academic staff. If your province has ROS requirements, you can advocate for IMG physicians to be offered an attractive sign-on package when they complete their ROS, to support diversity and inclusion through the recruitment of IMG faculty.
    • Create pre-residency externship positions to allow IMG physicians to gain experience working in Canadian health care settings.
    • Advocate at the national level for your specialty to develop accelerated residency or practice-ready programs across Canada for IMG physicians who have years of work experience in your specialty.
    • Advocate for innovation in the selection criteria for the IMG matching process by incorporating equity, diversity and inclusion principles.

Conclusion

IMGs are now a large part of the physician/professional workforce in Canada. There are significant training entry barriers and challenges in fully integrating IMGs into the training programs. Supporting and integrating IMG learners requires a careful learner centered approach with dedicated faculty development and change in organizational culture. Program directors can be innovative leaders and change makers to facilitate transition and integration process of IMG physicians.

Case resolution

Using a careful, learner-centred approach, Dr. Tomah ascertains Dr. Doe’s understanding of her postgraduate residency training integration and transition process. Dr. Doe tells Dr. Tomah that her family immigrated to Canada when she was seven years old, and she received the remainder of her elementary and high school education here. She went to her parents’ home country after high school to study for her MD degree. She graduated about a year ago and got matched via CaRMs on her first try. She had no Canadian clinical work experience (electives). In her undergraduate medical training, students worked in a protected environment with no major responsibilities other than helping senior residents and faculty when asked. They were not supposed to volunteer information unless asked directly, and it was expected that they would not ask for help but rather would figure things out on their own. Asking for help was considered a weakness. Dr. Tomah matches Dr. Doe with a senior IMG peer mentor and ensures that an IMG faculty member (not involved in her formal evaluations) is also available to her through the residency program. Confidential one-on-one communication and constructive feedback with dedicated ongoing support help her immensely to adapt to her new work environment. She successfully transitions into her residency program and completes her training, becoming a practising physician in Canada.

References

  1. 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. Adv Health Sci Educ Theory Pract. 2019;24(1):103–23.
  2. Sullivan P. Shut out at home, Canadians flocking to Ireland’s medical schools — and to an uncertain future. 2000;162(6):868–71.
  3. Wong A, Lohfeld L. Recertifying as a doctor in Canada: international medical graduates and the journey from entry to adaptation. Med Educ. 2008;42(1):53–60.
  4. Curran V, Hollett A, Hann S, Bradbury C. A qualitative study of the international medical graduate and the orientation process. Can J Rural Med. 2008;13(4):163–9.
  5. Kehoe A, McLachlan J, Metcalf J, Forrest S, Carter M, Illing J. Supporting international medical graduates’ transition to their host-country: realist synthesis. Med Educ. 2016; 50(10):1015-32.
  6. Association of Faculties of Medicine of Canada. The future of medical education in Canada: a collective vision for postgraduate medical education in Canada. Ottawa: Association of Faculties of Medicine of Canada; 2012. Available from: https://www.afmc.ca/resources-data/social-accountability/future-of-medical-education-in-canada/