International Medical Graduates- Changing Our Teaching Strategies for Changing Residents Katherine Neely, MD Nithya Guhanand, MD Forbes Family Practice Residency

Objectives Understand critical differences between IMGs and AMGs Understand critical differences between IMGs and AMGs Consider possible program modifications to maximize the learning environment for IMGs Consider possible program modifications to maximize the learning environment for IMGs Increase understanding of the perspective of and challenges facing IMGs Increase understanding of the perspective of and challenges facing IMGs Develop program modifications to address IMG challenges Develop program modifications to address IMG challenges

What are YOUR goals?

Outline of Workshop Sharing Forbes Experience Sharing Forbes Experience Literature Review and IMG Focus Group Literature Review and IMG Focus Group The View From the Other Side- a Personal Story The View From the Other Side- a Personal Story

Outline of Workshop Small Group Case Discussions Small Group Case Discussions –Interview –Orientation –Ongoing Teaching Large Group Sharing Large Group Sharing Conclusions and Future Plans Conclusions and Future Plans

Interview Language and Communication Language and Communication Medical Knowledge Medical Knowledge Commitment to Family Medicine Commitment to Family Medicine Psychosocial Awareness Psychosocial Awareness Initiative to Learn Initiative to Learn Intellectual Honesty Intellectual Honesty

Language and Communication Ask for a story Ask for a story –listen for use of tense and syntax Ask unexpected questions Ask unexpected questions –IMGs practice interview questions –Listen to accent, vocabulary Not culturally invasive Not culturally invasive –What is that?

Medical Knowledge Video case with oral presentation Video case with oral presentation –Comprehension –Recognition of severity –Ability to glean and organize data

Commitment to Family Medicine Any fellowship interests? Any fellowship interests? How would a Family Doctor approach this? How would a Family Doctor approach this? Tell me about a clinical case that changed your idea about Family Medicine? Tell me about a clinical case that changed your idea about Family Medicine? International Medical Graduates and a Program of Excellence, Goodell, Willard, and David, RAP 2007

Psychosocial Awareness “Emotional Intelligence” “Emotional Intelligence” Ability to use English to develop a connection Ability to use English to develop a connection Willingness to learn new ways of interacting Willingness to learn new ways of interacting Ability to consider new ideas Ability to consider new ideas –Death and dying, sexuality, abuse…

Initiative to Learn Residency as a hoop to jump Residency as a hoop to jump versus versus Residency as an opportunity Residency as an opportunity

Intellectual Honesty Perhaps not the most culturally Perhaps not the most culturally sensitive title- what is honesty? sensitive title- what is honesty? Ability to admit lack of knowledge Ability to admit lack of knowledge –To self –To those in authority Willingness to shift from cultural expectation of total competence to US openness to constructive criticism Willingness to shift from cultural expectation of total competence to US openness to constructive criticism

Orientation Learn a new system Learn a new system Confidence Confidence –Teachers in IMGs –IMGs in Teachers Patient interviewing Patient interviewing Conversations about culture Conversations about culture

Orientation One week One week Expected certain similar knowledge Expected certain similar knowledge Group bonding Group bonding Rules and regs of residency Rules and regs of residency

Intro to Family Medicine One month enculturation One month enculturation Develop concept of Family Medicine Develop concept of Family Medicine Delay contact with specialist rotations Delay contact with specialist rotations Assess and address different starting points Assess and address different starting points Begin remediation plans Begin remediation plans

The Outpatient Visit Observe faculty Observe faculty See patients with faculty at Med Student level See patients with faculty at Med Student level Begin to develop own patient panel Begin to develop own patient panel Use Direct Observation form Use Direct Observation form –Learn what we expect in a visit

Patient Interviewing Course Modified 1 st year Med Student course Modified 1 st year Med Student course 4 sessions with Patient Simulators 4 sessions with Patient Simulators Goals Goals –Learn to listen –Use open ended questions –Address emotion –Get feedback from “patients”

Address Cultural Issues Bayer International Cultural Consultant Bayer International Cultural Consultant Sessions for faculty, staff, and residents Sessions for faculty, staff, and residents Begin conversation about cultural similarities and differences Begin conversation about cultural similarities and differences Language fluency evaluations and remediation Language fluency evaluations and remediation

Literature Review Six useful articles Six useful articles Primary themes: Primary themes: –Cultural Competence –Stress of Adjustment –Communication Skills

Literature Summary Minimal training in behavioral medicine Minimal training in behavioral medicine Primary care medicine does not include mental health/psychosocial Primary care medicine does not include mental health/psychosocial Language issues: hard to format questions in English Language issues: hard to format questions in English Medical interviewing less emphasized or focused on content Medical interviewing less emphasized or focused on content

Literature Summary Doctor-patient relationship more hierarchical, authoritarian, without continuity Doctor-patient relationship more hierarchical, authoritarian, without continuity Perceptual differences Perceptual differences –US family life isolated –Medicalization of normal life stresses

Literature Summary Documentation new Documentation new Shift in relationship with support staff Shift in relationship with support staff Insecurity manifesting as constant need to prove themselves to faculty Insecurity manifesting as constant need to prove themselves to faculty

What do our residents experience?

IMG Focus Group What an Eye Opener!

Model of Care US model unfamiliar and very different US model unfamiliar and very different Other models of care Other models of care –60 or more patients a day, NOT privately –Business only no casual talk no casual talk no empathy no empathy no consideration of hidden agenda no consideration of hidden agenda –Hierarchy more absolute

“Facts” Conflict with US System “Facts” Conflict with US System Speed equals competency Speed equals competency Doctors should know everything Doctors should know everything –Corollary: Admitting lack of knowledge forfeits competency Questions about anything but chief complaint are inappropriate and invasive Questions about anything but chief complaint are inappropriate and invasive

“Facts” Continued Medical interview equals closed-ended questions to gather specific data. Medical interview equals closed-ended questions to gather specific data. The doctor’s job is to tell the patient what to do The doctor’s job is to tell the patient what to do

An IMG Perspective Nithya Guhanand, MD

Indian Joint Family

Modern Indian joint family

Women in the rural joint family

Indian medical students

Doctor attending to a patient

Doctor examining patient Women prefer female doctors. Women prefer female doctors.

Examining female patients e

Examining children

Hospitals private

Private hospitals-Bangalore

Teaching Hospitals

Mission Hospitals

Mercy mission hospital

Waiting outside a clinic

Government hospital services

General ward in government hospital

A crowded ward after a train wreck

Visiting family

Doctor in a government hospital

Waiting-patient with leprosy-in govt.hospital in Karachi

procedures

Mental Health “only for crazy people” Little or no training in common psychiatric illnesses Little or no training in common psychiatric illnesses US culture “too pampered,” US culture “too pampered,” One doesn’t talk about psychiatric problems One doesn’t talk about psychiatric problems “Nerves” “Nerves”

Behavioral Science Emotions are not talked about Emotions are not talked about –Difficulty reading emotional body language –Difficulty with English vocabulary for emotions Giving bad news is done indirectly to family or not at all Giving bad news is done indirectly to family or not at all

Cultural Adjustment Impedes Medical Learning IMG behavior perceived as avoidance, lack of knowledge, skills, or interest IMG behavior perceived as avoidance, lack of knowledge, skills, or interest –many changes –potential for mistakes at every turn Social conversation new and intrusive Social conversation new and intrusive –how was your weekend? Fear of rejection as a foreigner Fear of rejection as a foreigner

Cultural Education Cultural Consultant rejected Cultural Consultant rejected Generalizations about them by an American uncomfortable Generalizations about them by an American uncomfortable Let them teach us and each other Let them teach us and each other Happy to talk about differences Happy to talk about differences

In Summary

The difference between the competent doctors IMGs were trained to be and US expectations of competent family doctors was striking. The difference between the competent doctors IMGs were trained to be and US expectations of competent family doctors was striking.

Our broader histories and our social conversation feel very invasive.

Deep-seated fear and insecurity created by so many changes takes months to improve. Deep-seated fear and insecurity created by so many changes takes months to improve.

Entering an environment fraught with danger: mistakes, rejection, loss of face, loss of dream. It’s no wonder most IMGs appear avoidant at first. Entering an environment fraught with danger: mistakes, rejection, loss of face, loss of dream. It’s no wonder most IMGs appear avoidant at first.

Family Medicine training expects IMGs to give up their previous sense of competency and status, violate their previous boundaries, and do so with people they don’t yet trust in a system they know is prejudiced against them.

The US cultural perception of their natural withdrawal creates the impression of incompetence and lack of interest. The US cultural perception of their natural withdrawal creates the impression of incompetence and lack of interest.

The power of that first impression endures.

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