1. Identifying International Medical Graduates (IMGs’) Language and Communication learning needs using a combined linguistic and clinical approach
Ann Smalldridge, Duncan Cross
Reache North West
Introduce self and Duncan
Structure of the talk
Say a bit about REACHE which is the organisation we come from and the work we do
Tell you about background to this project - the problems IMGs face and the national and international context
Tell you about the courses we ran and what we found

2. Reache North West
Refugee and Asylum Seekers Centre for Healthcare Professionals Education
Established 2003
Funded by NHS North
Work regionally and nationally to provide education, training and support
Based in Salford Royal Foundation trust
major teaching hospital
NW England
Greater Manchester

3. Team
Language tutors – 4
Clinical Tutors – Hospital Consultant, GP and Nursing backgrounds
Volunteers
Simulated patients
Administrative staff

4. Support provided Advice and guidance English tuition
Registration examination (PLAB) tuition
Preparing for work in UK health care
Communication skills
Clinical placements
Job search skills
Requirements for registration as a doctor in the UK:
Minimum linguistic ability +
Professional registration examination
Relevant documentation
PLUS extras needed to be safe and effective doctors in the UK
supported nearly 400 imgs
xxx doctors have now returned to work in their professional role in the NHS

5. Results
135 Refugee Healthcare Professionals returned to their Professional Roles in the National Health Service (NHS)
Remediation for International Medical Graduates (IMGs) in post-graduate medical training
Refugees returned to work but also in the last few years we have become more involved with remediation of IMGs
I will explain more about this in a minute but we and others have realised that the skills we have can be applied to other international graduates as many of the problems they face and learning needs are the same
(Also nurses/midwives dentists pharmacists
Some go into non professional roles – HCA, notes summarisers, pharmacy etc)
Pause and lead into -
I am now going to talk about the problems that IMGs face – in GP, in the uk and more genrally

6. IMGs in the UK
78,898 of doctors registered with the General Medical Council (2011) identify themselves as having trained overseas - 33% of all registered
Increasing awareness of language, communication difficulties of IMGs
IMGs are over-represented in referrals to GMC
Publicity around mistakes, high profile cases

7. GP Training
In % Non-UK graduates failed the Clinical Skills Assessment (CSA) part of the nMRCGP vs 74% UK graduates
2012 Northwest Deanery - 45 extensions of training due to CSA failure - cost of £35,000 each
Trainers report difficulty defining language and communication issues that underlie performance problems
Specifically in GP training
628 Non Uk graduates failed the CSA in 2010
16 of the 20 UK deaneries have a failure rate higher than 40% for non UK graduates
Using the self-reported categories of ‘White’ and ‘Asian’, the respective pass rates are, for the CSA – 93% and 66%. The RCGP has analysed the CSA results for evidence of examiner bias against ethnic candidates and has not found any. The ethnicity of examiners does not contribute to this effect and the reasons for failure are similar across all subgroups.
Further light on the question of ethnicity is shed by looking at the place of primary medical qualification of the candidates. T
his may account for some of the differences; if we look for example at Asian candidates who qualified in the UK versus those who qualified overseas, we find pass rates in the CSA 83% v. 56%
Perhaps we should not be surprised that training to be a doctor overseas is associated with less success than training in the UK in an exam that assesses competence in British general practice.

8. Supporting Evidence UK - Warwick Report, Illing et al
International - e.g. Pilotto et al, Woodward-Kron
Anaesthetics & Psychiatry Post graduate examinations
Lots of concern –
GMC commissioned a report ‘ The state of medical education and Practice in the UK ( sept 11). This has documented the difficulties faced by some overseas doctors adapting to practice in the NHS. It has called for more competency testing and induction by employers and the GMC are taking this forward at the moment with some pilot projects
Warwick report 2009 commissioned by the GMC to look into problems experienced by IMGs in the UK and also Pilotto et al in 2007 ( systmatic review of literature on IMGs) - identified concerns with regards to IMG language and communication skills including question formation, colloquial language, appropriate word choice to express empathy
Research shows that doctors whose primary qualification is outside the UK are more likely to fail UK postgraduate exams and be reported to regualtory bodies
Not restricted to UK- Dr Woodward Kron, a linguist has done very important work in this field in Australia
Also not just GPs – similar findings are reported in psychiatry and anaesthetics PG exams
Pause again – lead into
we have done a lot of work on language and communication skills teaching at REACHE and wanted to expand this into this important area which has major implications of patient safety and doctors own careers

9. Identifying needs – our aims
Formal assessments of GP Trainees identified as having ‘communication problems’
Combined linguistic and clinical approach
Provide a report and recommendations for remediation
who?
We set up sessions for IMG GP trainees in their 2nd or 3rd year who were identified by their trainers, themselves, the course organisers or the deaneries as having ‘communication problems/had either or were thought likely to fail the CSA
What?
We used a combined approach using English Language specialist teachers and clinicians to analyse what the problems were
Why?
Our aim was to provide feedback , either on the day or in writing and some recommendations for further action to remedy the problem
we hoped that eventually this would lead to cost savings in terms of fewer CSA fails and extension training and improved skills for trainers to pick up and remedy problems at an earlier stage

10. Method
Doctors were observed undertaking three scenarios –two patient based and a handover to a colleague
Simulated Patients (SPs) gave feedback from the patient’s perspective
Clinical and Language Tutors observed and assessed the scenarios
We have run this course twice with slightly different formats
Both courses used 3 scenarios:
1 history taking for a SP
I explaining to a SP and discussing a management plan
1 handing over a case to a colleague
All the scenarios were observed by a language tutor and a clinical tutor
One course – we provided a written report at the end of the day by combining everyones assessment. We then made some recommendations for further learning
The second course – we gave direct feedback to the doctors at the time form the linguist, clinical and patients perspective and gave them opportunities to practice again

11. Findings Linguistic Issues Communication Issues Cultural Issues
Consultation Skills
Findings
We found common language and communication themes in both courses, also cultural issues which inhibited good consulting in all stages of the consultation in both the patient based scenarios
We found the handover to a colleague particularly revealing – it brought out a lot of missed cues, misunderstanding of cultural references and some understanding of the doctors insight
. I am going to break these down

12. Linguistic problems Pace, intonation, accents, rhythm, pronunciation
Grammatical errors, sentence structure, tenses
Colloquial Language: techniques for clarifying
Understatements, euphemisms, humour, irony

13. Communication issues
Adapting language to the patient and the problem, avoiding stock phrases
Picking up cues
Expressing Empathy
Vocabulary

14. Cultural issues Speaking about sex and death
Understanding social context
Medico-legal and ethical framework of UK
Doctor centeredness, patient autonomy

15. Consultation skills Establishing rapport Information gathering
Seeking patients’ needs and preferences (ICE)
Explaining - especially uncertainty
Negotiating-Influencing language
Decision making in consultations
Establishing rapport, inc non verbal
Information gathering
Clarification of unfamiliar terms
Demonstrating genuine interest
Tick box approach
Seeking patients’ needs and preferences ( ICE)
Explaining
Attitudinal, cultural and professional values around the amount and type of information patients expect in the UK
Sharing understanding- integrating ICE
Explaining medical conditions and treatment
Explaining uncertainty, wait and see rather than curing, offering reassurance
Negotiating
Negotiating a management plan with a range of options
Influencing language
Decision making in consultations
Poor use of time
Handling uncertainty
Failure to integrate or apply what has been heard in the first half of the consultation

16. Overall impressions
Consultations were disorganised and doctor centred despite superficial conformity with expected UK norms

17. Evaluation
The feedback from the North West trainees was that they wished they had more of this training and feedback and at an earlier stage as it provided useful insights.
The project also successfully used a multi-disciplinary team in assessing and teaching trainees in a practical manner.

18. Conclusion
Using a combined linguistic and clinical assessment can uncover problems that inhibit good consulting.

19. Thank you for listening.