Moving into medical practice in a new community: Supporting the physician through the transition

1. Moving into medical practice in a new community: Supporting the physician through the transition Jocelyn Lockyer Associate Dean, Continuing Medical Education and Professional Development Professor, Department of Community Health Sciences

2. Team • Jocelyn Lockyer PhD • Keith Wycliffe-Jones MB ChB FRCGP • Maitreyi Raman MD MSc FRCPC • Amonpreet Sandhu MD FRCPC • Herta Fidler MSc

3. Disclosure • The study was funded by the Office of Continuing Medical Education and Professional Development • Nothing to disclose

4. Background • Physicians face many transitions • Pre-clinical – Clinical • UG – PG • PG – Practice • Practice • Breaking in • Fitting in • Getting out • Bennett & Hotvedt 1999

5. Transitions • Require reforming concepts of ways-of-being and identity • Represent a process involving a fundamental re-examination of one’s self • Wilkie & Rafaella, 2005

6. Transitions are facilitated by • Collegial support • Enhanced clinical skills • Workplaces that foster good interpersonal relationships and integrate newcomer into workplace

7. Transitions can be traumatic • Studies of International Medical Graduates who settle into a new country show • Major learning curve • Types and prevalence of different diseases • Different systems • Tacit knowledge • Referrals • DI/Lab • Prescribing • Billing/funding • Family/home/personal issues • Lockyer et al 2007; Klein et al 2009;

8. Research Goal • Explore the experiences of physicians as they entered practice in a new community

9. Context….Calgary in Oil & Gas Boom • Unprecedented city growth from 950,000 to 1.2 million (2005 and 2010) • Pressure on public services • Constant recruitment of health professionals • City was a construction zone

10. Design • Interviews • 30 – 60 minutes • Recruited • MDs who came within 12-18 months • Worked a minimum of 30 hours/week • Family Medicine, Internal Medicine, Pediatrics

11. Interviews queried • Reasons for coming • Type of practice • What made it easy or difficult to enter into practice • Utility of • Colleagues • Educational programs • Information sources

12. Data analysis • Transcribed interviews • Grounded theory • Initial coding of first transcript by all • Agreement on coding • Constant comparison and meetings throughout • Adjustment of interview protocol as needed

13. Results • 10 women and 10 men • 9 months to 34 years in practice • 12 Canadian graduates; 8 international • 8 internal medicine; 6 family medicine; 6 pediatrics

14. Dimensions and processes

15. Location Positive Negative A lot of times you get bad service here. (#14) I see a lot of stress going around this town, and I tell you a lot of people come in depressed and all that. (#15) • Calgary culturally is much more diverse and we have an [ethnic] background. So my wife was quite pleased because we have the temples and more activities for the daughters. (# 16)

16. Location Positive Negative Infrastructure under construction (roads, public buildings) Shortage of skilled labor High costs of housing, rental and leasing • Excitement of dynamic and booming city • Range of entertainment • Cultural diversity • Potential for connections to community networks

17. Professional Context Positive Negative You know, there’s no one to tell you these are the steps you need to go through. I found that really frustrating and actually quite scary not knowing if I’ve done everything that I’ve needed to do. (# 8) • Primarily my practice is in [ subspecialty ]... There are only about 5 places in Canada where that is performed and this is obviously one of those centers. So I wanted to be able to practice in my area of specialty (#7)

18. Professional Context Positive Negative Less positive when Lack of administrative support Inadequate help with information technology Orientation lacking or absent Lack of help from ‘point’ person ‘Arrived’ without a position (e.g., for a spousal move) • Career move • Professional and personal development • Better work-life balance • Spousal opportunity • More positive with • Supportive workplace • Good collegiality • Adequate administrative and technical resources

19. Mediating Factors External Internal I do think that it’ s really important to just go in with an open mind and learn about how other people function in their area...It’s easy to jump into a new system and be critical. (# 18) • She [my spouse] did the most important part; … I think it’s nearly impossible without family support. (# 6) • Again I would say mostly the physician group… They were very helpful in terms of allowing me to assimilate into the practice group... (# 7)

20. Mediating Factors External Internal Personal attributes Skills and experience Ability to self advocate Self reliance Previous experiences with relocation Ability to tolerate, adapt to and accept differences Being organized • Assistance from other health care professionals • Support of family, friends and colleagues • Development of new professional, social and community networks • Attitude and support of colleagues in workplace, especially leaders • Flexibility

21. Dimensions and processes

22. Discussion • Support for newcomers was suboptimal • Physicians who had ‘better’ experiences had • Infrastructure support (colleagues, quality information, IT) • Were recruited • Personal skills that enabled adaptation • CPD rarely mentioned as a factor other than for ‘networking’ potential

23. Possible solutions • Formal/informal mentorship • Network facilitation (rounds, conferences, social activities) • Infrastructure to support newcomer and family • Office/IT support • Quality accessible web-based information • Point person • Collegiality • Tacit information exchange

24. Questions