International Medical Graduates: From Prevention to Remediation

1. International Medical Graduates: From Prevention to Remediation Alan A Monavvari MD, MHSc, MSc, CHE, CCFP Assistant Professor Associate Director, Recruitment and Admission

2. Faculty/Presenter Disclosure • Faculty: Alan A. Monavvari Perle Feldman Anne Wideman • Relationships with commercial interests: • Not Applicable

3. Disclosure of Commercial Support • This program has received NO Commercial support • This program has received NO in-kind support • Potential for conflict(s) of interest: • Not Applicable

4. Session Objectives • Assess the learning needs of the individual IMGs/CSAs • Identify IMGs/CSAs with early signs of difficulty requiring preventative measures • Recognize IMGs/CSAs with complex difficulty requiring remediation • Review past and current cases in your site/DFCM

5. Statistics The organizations currently involve in coaching, integration, assessment, evaluation and residency matching of International Medical Graduates are: • 1- HealthForceOntario: involve in coaching, integration and career advice • 2- Centre for Evaluation of Health Professionals Educated Abroad (CEHPEA): responsible for assessment, evaluation and Pre-Residency Program (PRP) • 3- Canadian Residency Matching System (CaRMS): central matching system for residency programs in Canada • 4- Ontario Family Medicine Program: a consortium of 6 Ontario’s Family Medicine Residency programs (McMaster, Northern, Ottawa, Queen’s, Toronto, Western) responsible for central selection of International Medical Graduates into Family Medicine programs.

6. International Medical Graduates in Canada A. Salman

7. International Medical Graduates in Canada A. Salman

8. Competition for IMG Positions Adapted from: CaRMS 2013 Number of applicants and matched positions for International Medical Graduates in Canada 2007-2013

9. NUMBER OF IMGS - 2010 With respect to the number of positions available in the first iteration of the CaRMS Match, the University of Toronto-FM is one of the largest IMG Programs in Canada CaRMS 1st iteration , 2010

10. NUMBER OF IMGS - 2010 With respect to the number of positions in the first iteration of the CaRMS Match, the University of Toronto-FM is one of the largest IMG Program in Ontario CaRMS 1st iteration , 2010

11. IMGs and CSAs • 2010 CARMS Canadian Students Studying Medicine Abroad Report • The term International Medical Graduate includes physicians who immigrated to Canada after finishing their MD (IMGs). It also includes Canadians who Studied Abroad (CSAs). In the past 5 years, the number of CSAs has increased significantly. CSAs also have been more successful in securing a residency position than IMGs. This report demonstrates the demographic of this particular pool of applicants, the CSAs. Knowing these demographics could assist faculty to prepare themselves with a completely different sets of challenges than their previous IMG cohorts.

12. Canadians Studied Abroad (CSAs) Adapted from: CaRMS 2010 CSA Report

13. School Adapted from: CaRMS 2010 CSA Report

14. Age Adapted from: CaRMS 2010 CSA Report

15. Gender Adapted from: CaRMS 2010 CSA Report

16. Marital Status Adapted from: CaRMS 2010 CSA Report

17. Physician Parents Adapted from: CaRMS 2010 CSA Report

18. Level of Education Before MD Adapted from: CaRMS 2010 CSA Report

19. Application to Canadian Schools Adapted from: CaRMS 2010 CSA Report

20. Motivation Adapted from: CaRMS 2010 CSA Report

21. Year of Graduation 417 550 999 1142 424 321 Adapted from: CaRMS 2010 CSA Report

22. Median Debt Adapted from: CaRMS 2010 CSA Report

23. Intention to Return Adapted from: CaRMS 2010 CSA Report

24. Postgraduate Choice Adapted from: CaRMS 2010 CSA Report

25. Specialty of Interest Adapted from: CaRMS 2010 CSA Report

26. Perceived Barriers Adapted from: CaRMS 2010 CSA Report

27. Early Detection Peer or Mentor support Reduced clinical workload Structured reading program Study group Time for increased practice and skill acquisition Consideration for “Forward feeding” Special courses/skills training Learning assessment Language/speech assessment (Steinert, Nasmith and Tannenbaum) 27 M. Gottesman

28. SOAP Subjective: use experience and opinion to gain an individualized impression of trainee Objective: Document specific examples of problem Assessment: Diagnose the problem Plan: develop and implement a plan to address the problem (Hicks, 2005) 28

29. Early Signs Resident seems not able to grasp EMR or keep asking same questions Orientation Computer literacy Organizational skills Analytical skills 29

30. Early Signs Resident seems not able to schedule time or find his/her way between point A and B Orientation Computer literacy Organizational skills Analytical skills 30

31. Early Signs Resident does not transition smoothly between clinics/services Orientation Anxiety Culture Common Sense Professionalism 31

32. Early Signs Resident Does not have enough knowledge or cannot apply his/her knowledge Rigidity Following Check Lists Approach/structure Differential Diagnoses Premature Closure Complexity Integration Positive/Negative Pertinent 32

33. Early Signs Resident seems not able to come up with a management plan Culture Integration Context Common Sense 33

34. Early Signs Resident seems not be patient-centric Culture Psychosocial Determinant of Health Community Services 34

35. Early Signs Resident seems not be able to deal with gray area of uncertainty Culture Anxiety Training Style Evidence-based 35

36. Early Signs Resident seems not be motivated Culture Anxiety Sense of Entitlement Responsibility Professionalism distractions 36

37. Learners in Trouble

38. Learners in Trouble • Prevalence 5.8-6.9% • Requires +++ time and effort • “Problem Learner” • perform significantly below their potential doe to specific difficulties • “Problem Resident” • demonstrates a significant enough problem that requires intervention by someone of authority (Hicks, 2005) A. Monavvari

39. IMG Residents in Trouble • Prevalence (anecdotal) 15-25% • Risk factors for developing problems as a resident: • Being older • Part of an underrepresented minority • IMGs • Elements that disadvantage these groups: • Cultural difference • Language difficulties • Expectations • Previous experiences (Hicks, 2005) A. Monavvari

40. SUCCESS • Dr. MacLellan’s study in Quebec looked at IMGs and graduates of Canadian schools who made it into residency programs from 2001 to 2008 and their results on the final, certification exams to determine if they can practice. The average pass rate for international graduates was 56%, versus 93.5% for the Canadians.

41. SUCESS • A separate study at Vancouver’s St. Paul’s Hospital, where a special program was set up for IMGs in 2006 to help them perform better, found the internationals did as well as Canadians on assessments during the training, but that their final exam pass rate was a “disappointing” 58%, compared to 97% for the Canadians.

42. Learners Challenges Easy To Manage Rude Hostile Too Casual and informal Avoids Work Does not Measure up Intellectually Avoids Patient Contact Does not Show Up Challenges Everything All Thumbs Poor Integration Skills Over-eager Cannot focus on what is important Disorganized Disinterested A Poor Fund of Knowledge Frequent Less Frequent Bright With Poor Interpersonal Skills Excessively Shy, Non-Assertive Cannot Be Trusted A Psychiatric Problem A Substance Abuse Problem “Con Artist” (Manipulative) Hicks PJ, Cox S. et al Amer J Obstet 193 :2005 Difficult To Manage A. Monavvari

43. Root Cause Performance Below standard, anxious, in difficulty WHY? Scholar Integration Analytical and interpersonal skills Collaborator Communicator WHY? Organization Time Management, Disorganized Manager WHY? Knowledge Knowledge Base, Approach Medical Expert Health Advocate WHY? Self-awareness Insight, Common Sense Confidence Professional Scholar WHY? 43

44. Interaction Between Challenges Environment Learner Teacher A. Monavvari

45. Guide Challenge: Needs mild prevention from preceptor and/or site remediation Solution: Few suggestions 45

46. Environmental Challenges 1- Clinical Setting Orientation Objectives/Expectations 2- Workload Clinical Hours On Calls Complexity 3- Support Program Director Preceptor Peers Coaching/Mentorship

47. Case 1: Professionalism Resident arrives always late in your office • Travel time between Hospital and clinic • Does not drive • Shy to tell other preceptor he/she needs to leave early • Other preceptor reviews all the cases at the end of session

48. Case 1: Solution Schedule resident to minimize travel time Match resident/preceptor based on accessibility Discuss Professionalism/Travel time in your orientation session Discuss with other preceptor to release resident earlier Document clear expectations, objectives, tasks and policies in residents handbook

49. Case 2: Professionalism Resident missed many academic half-days • Expectations not clear from the program

50. Case 2: Solution Emphasize priorities during orientation session Meet with program director Ask to reflect