IMGsIMGs

Workshop 2012Workshop 2012

DefinitionDefinition

Non-UK/EU Medical School GraduatesNon-UK/EU Medical School Graduates

Why discuss IMGs?Why discuss IMGs?

Frequently ‘Trainees in Difficulty’Frequently ‘Trainees in Difficulty’

Increasing numbersIncreasing numbers

TodayToday

What are the issues?What are the issues?

How can we help?How can we help?

Questioning our assumptions?Questioning our assumptions? Understanding the challenges?Understanding the challenges?

CSACSA

Failure rates (2010)Failure rates (2010)

UK Graduate: 8.4%UK Graduate: 8.4% EU Graduate: 28%EU Graduate: 28% Non-EU Graduate: 46% Non-EU Graduate: 46%

IMGs @ first attempt: 50%IMGs @ first attempt: 50%

CSACSA

Dichotomous predictors of variation Dichotomous predictors of variation in outcome scores:in outcome scores:

UK/Non-UK grads 30%UK/Non-UK grads 30% White/non 3%White/non 3% Gender 2%Gender 2% Age 1%Age 1%

CSACSA

Similar results in all other College Similar results in all other College examsexams

Even more striking in…Even more striking in…

……..Psychiatry..Psychiatry

What are the issues?What are the issues?

Think about an IMG Think about an IMG

RM, 32 year old manRM, 32 year old man Graduated Med School in India 2006Graduated Med School in India 2006

Now arrives as your ST2, first GP Now arrives as your ST2, first GP placementplacement

What are the issues?What are the issues?

In groups of fourIn groups of four

Brainstorm what are the challenges Brainstorm what are the challenges for him for him that a UK graduate may not that a UK graduate may not faceface??

We will look at solutions later…We will look at solutions later…

What are the issues?What are the issues?

LanguageLanguage

Educational experienceEducational experience

CultureCulture

Life stage/personal stressLife stage/personal stress

Life stage/personal stressLife stage/personal stress

Evidence: IMGs experience more Evidence: IMGs experience more emotional stressemotional stress

Displacement, separation, financialDisplacement, separation, financial

CultureCulture

Trainees need to:Trainees need to:

Understand the Understand the contextcontext in which in which patients present & what motivates patients present & what motivates them. them.

Respond to behaviour based on Respond to behaviour based on societal norms.societal norms.

May never have been inside a UK home.May never have been inside a UK home.

““Double consciousness”Double consciousness”

W.E.B du Bois (African American W.E.B du Bois (African American Harvard Graduate)Harvard Graduate)

Compartmentalisation of mental life: Compartmentalisation of mental life: distinct spheres separating public distinct spheres separating public and private selfand private self

Fear of being found out = STRESSFear of being found out = STRESS

Educational cultureEducational culture

SDL/reflective model may be SDL/reflective model may be unfamiliarunfamiliar

Deference to teacher? Fear of Deference to teacher? Fear of admitting ‘shortcomings’?admitting ‘shortcomings’?

May value doctor centred approach May value doctor centred approach and medical knowledgeand medical knowledge

LanguageLanguage

Self reporting of English as second Self reporting of English as second language surprisingly LOWlanguage surprisingly LOW

Many (eg India) med schools taught Many (eg India) med schools taught in Englishin English

All non EU doctors will have PLABAll non EU doctors will have PLAB

LanguageLanguage

accent, colloquialismaccent, colloquialism style of English eg old fashioned in style of English eg old fashioned in

IndiaIndia humour, ironyhumour, irony features of conversational structure eg features of conversational structure eg

turn-taking & use of silenceturn-taking & use of silence manners: greeting, politeness, saying manners: greeting, politeness, saying

no, expressing angerno, expressing anger

LanguageLanguage

paralinguistic features of speech: paralinguistic features of speech: emphasis, pace, intonation, volume emphasis, pace, intonation, volume (Spanish/Italian may seem over (Spanish/Italian may seem over emotional) emotional)

non verbal communication: eg space, non verbal communication: eg space, touch (more likely in S America), eye touch (more likely in S America), eye contact (avoided in Nigeria), contact (avoided in Nigeria), gestures, facial expressiongestures, facial expression

Linguistic CapitalLinguistic Capital

Cultural capitalCultural capital: forms of knowledge, skills, : forms of knowledge, skills, education, and advantages that a person education, and advantages that a person has, which give them a higher status in has, which give them a higher status in society.society.

Linguistic capital:Linguistic capital: The mastery of The mastery of language = a form of embodied cultural language = a form of embodied cultural capital in that it represents a means of capital in that it represents a means of communication and self-presentation communication and self-presentation acquired from one's surrounding culture. acquired from one's surrounding culture. (Bourdieu)(Bourdieu)

So what does that mean?So what does that mean?

‘‘Double consciousness’Double consciousness’ Fear of being found outFear of being found out StressStress Increased inability to use linguistic Increased inability to use linguistic

capitalcapital

So what does that mean?So what does that mean?

Trainees mayTrainees may over modelover model: stick to linear consultation : stick to linear consultation

model or use platitudesmodel or use platitudes notnot pick up on patient frustration/anxiety pick up on patient frustration/anxiety notnot seem patient-centred, or empathic seem patient-centred, or empathic Seem Seem disorganised and chaoticdisorganised and chaotic when when

attempting spiral (not linear) attempting spiral (not linear) consultationsconsultations

Examples from Prof Celia RobertsExamples from Prof Celia Roberts http://www.bradfordvts.co.uk/wp-http://www.bradfordvts.co.uk/wp-

content/onlineresources/content/onlineresources/0307teachinglearning/0307teachinglearning/internationalmedicalgraduates/theinternationalmedicalgraduates/the%20csa%20and%20IMGs%20by%20csa%20and%20IMGs%20by%20celia%20celia%20roberts.ppt#266,11,Slide 11%20roberts.ppt#266,11,Slide 11

So how can we help?So how can we help?

Back in our fours…Back in our fours…

How can we help RM? Think of How can we help RM? Think of practical steps that may be useful.practical steps that may be useful.

Remember the 4 issues…Remember the 4 issues…

Remember the four issues…Remember the four issues…

LanguageLanguage

Educational experienceEducational experience

CultureCulture

Life stage/personal stressLife stage/personal stress

Early evaluationEarly evaluation

Create SAFE environment : stress and Create SAFE environment : stress and alienation impact on ability to learnalienation impact on ability to learn

Kiddy RingKiddy Ring http://www.dundee.ac.uk/gptraining/http://www.dundee.ac.uk/gptraining/

SPTC%20Files/CD%20Rom/Unit%201/SPTC%20Files/CD%20Rom/Unit%201/The%20Kiddie%20Ring.rtfThe%20Kiddie%20Ring.rtf

Get to know them / Invite them homeGet to know them / Invite them home

Observation & feedback is Observation & feedback is key:key:

VideosVideos Joint surgeriesJoint surgeries Sitting inSitting in

Address issues directlyAddress issues directly Emphasise no need to prove medical Emphasise no need to prove medical

knowledgeknowledge

Key tutorialsKey tutorials

Early: Role of GP, patient Early: Role of GP, patient expectations, health seeking expectations, health seeking behaviourbehaviour

EthicsEthics Sexuality, death etcSexuality, death etc Non medical consultationsNon medical consultations Explaining common conditions to Explaining common conditions to

patientspatients

Encourage trainee toEncourage trainee to

Recognise and value patient centred Recognise and value patient centred consulting earlyconsulting early

Be curious about patient livesBe curious about patient lives Study group with non IMGs (to avoid Study group with non IMGs (to avoid

collusion)collusion) Culture eg magazines, soapsCulture eg magazines, soaps Embed in team: social events, learn Embed in team: social events, learn

from all stafffrom all staff

ResourcesResources

http://www.londondeanery.ac.uk/var/http://www.londondeanery.ac.uk/var/language-and-communication-language-and-communication-resource-unitresource-unit

http://www.londondeanery.ac.uk/var/http://www.londondeanery.ac.uk/var/international-medical-graduates/international-medical-graduates/international-medical-graduates/?international-medical-graduates/?searchterm=imgsearchterm=img

http://www.londondeanery.ac.uk/var/http://www.londondeanery.ac.uk/var/language-and-communication-language-and-communication-resource-unitresource-unit

http://www.londondeanery.ac.uk/var/http://www.londondeanery.ac.uk/var/international-medical-graduates/international-medical-graduates/international-medical-graduates/?international-medical-graduates/?searchterm=imgsearchterm=img

SummarySummary

Be Be awareaware of challenge of challenge Commit the Commit the timetime Create the Create the safestsafest of environments of environments Don’t shy away from addressing the Don’t shy away from addressing the

issuesissues