1. IMGs Workshop 2012

2. Definition Non-UK/EU Medical School Graduates Non-UK/EU Medical School Graduates

3. Why discuss IMGs? Frequently ‘Trainees in Difficulty’ Frequently ‘Trainees in Difficulty’ Increasing numbers Increasing numbers

4. Today 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?

5. CSA 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%

6. CSA Dichotomous predictors of variation in outcome scores: Dichotomous predictors of variation 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%

7. CSA Similar results in all other College exams Similar results in all other College exams Even more striking in… Even more striking in… …..Psychiatry …..Psychiatry

8. What are the issues? Think about an IMG Think about an IMG RM, 32 year old man RM, 32 year old man Graduated Med School in India 2006 Graduated Med School in India 2006 Now arrives as your ST2, first GP placement Now arrives as your ST2, first GP placement

9. What are the issues? In groups of four In groups of four Brainstorm what are the challenges for him that a UK graduate may not face? Brainstorm what are the challenges for him that a UK graduate may not face? We will look at solutions later… We will look at solutions later…

10. What are the issues? Language Language Educational experience Educational experience Culture Culture Life stage/personal stress Life stage/personal stress

11. Life stage/personal stress Evidence: IMGs experience more emotional stress Evidence: IMGs experience more emotional stress Displacement, separation, financial Displacement, separation, financial

13. Culture Trainees need to: Trainees need to: Understand the context in which patients present & what motivates them. Understand the context in which patients present & what motivates them. Respond to behaviour based on societal norms. Respond to behaviour based on societal norms. May never have been inside a UK home. May never have been inside a UK home.

14. “Double consciousness” W.E.B du Bois (African American Harvard Graduate) W.E.B du Bois (African American Harvard Graduate) Compartmentalisation of mental life: distinct spheres separating public and private self Compartmentalisation of mental life: distinct spheres separating public and private self Fear of being found out = STRESS Fear of being found out = STRESS

15. Educational culture SDL/reflective model may be unfamiliar SDL/reflective model may be unfamiliar Deference to teacher? Fear of admitting ‘shortcomings’? Deference to teacher? Fear of admitting ‘shortcomings’? May value doctor centred approach and medical knowledge May value doctor centred approach and medical knowledge

16. Language Self reporting of English as second language surprisingly LOW Self reporting of English as second language surprisingly LOW Many (eg India) med schools taught in English Many (eg India) med schools taught in English All non EU doctors will have PLAB All non EU doctors will have PLAB

17. Language accent, colloquialism accent, colloquialism style of English eg old fashioned in India style of English eg old fashioned in India humour, irony humour, irony features of conversational structure eg turn-taking & use of silence features of conversational structure eg turn-taking & use of silence manners: greeting, politeness, saying no, expressing anger manners: greeting, politeness, saying no, expressing anger

18. Language paralinguistic features of speech: emphasis, pace, intonation, volume (Spanish/Italian may seem over emotional) paralinguistic features of speech: emphasis, pace, intonation, volume (Spanish/Italian may seem over emotional) non verbal communication: eg space, touch (more likely in S America), eye contact (avoided in Nigeria), gestures, facial expression non verbal communication: eg space, touch (more likely in S America), eye contact (avoided in Nigeria), gestures, facial expression

19. Linguistic Capital  Cultural capital: forms of knowledge, skills, education, and advantages that a person has, which give them a higher status in society.  Linguistic capital: The mastery of language = a form of embodied cultural capital in that it represents a means of communication and self- presentation acquired from one's surrounding culture. (Bourdieu)

20. So what does that mean? ‘Double consciousness’ ‘Double consciousness’ Fear of being found out Fear of being found out Stress Stress Increased inability to use linguistic capital Increased inability to use linguistic capital

21. So what does that mean? Trainees may Trainees may over model: stick to linear consultation model or use platitudes over model: stick to linear consultation model or use platitudes not pick up on patient frustration/anxiety not pick up on patient frustration/anxiety not seem patient-centred, or empathic not seem patient-centred, or empathic Seem disorganised and chaotic when attempting spiral (not linear) consultations Seem disorganised and chaotic when attempting spiral (not linear) consultations

22. Examples from Prof Celia Roberts Examples from Prof Celia Roberts http://www.bradfordvts.co.uk/wp- content/onlineresources/0307teachinglear ning/internationalmedicalgraduates/the%2 0csa%20and%20IMGs%20by%20celia%2 0roberts.ppt#266,11,Slide 11 http://www.bradfordvts.co.uk/wp- content/onlineresources/0307teachinglear ning/internationalmedicalgraduates/the%2 0csa%20and%20IMGs%20by%20celia%2 0roberts.ppt#266,11,Slide 11

23. So how can we help? Back in our fours… Back in our fours… How can we help RM? Think of practical steps that may be useful. How can we help RM? Think of practical steps that may be useful. Remember the 4 issues… Remember the 4 issues…

24. Remember the four issues… Language Language Educational experience Educational experience Culture Culture Life stage/personal stress Life stage/personal stress

25. Early evaluation Create SAFE environment : stress and alienation impact on ability to learn Create SAFE environment : stress and alienation impact on ability to learn Kiddy Ring Kiddy Ring http://www.dundee.ac.uk/gptraining/SPTC %20Files/CD%20Rom/Unit%201/The%20 Kiddie%20Ring.rtf http://www.dundee.ac.uk/gptraining/SPTC %20Files/CD%20Rom/Unit%201/The%20 Kiddie%20Ring.rtf http://www.dundee.ac.uk/gptraining/SPTC %20Files/CD%20Rom/Unit%201/The%20 Kiddie%20Ring.rtf http://www.dundee.ac.uk/gptraining/SPTC %20Files/CD%20Rom/Unit%201/The%20 Kiddie%20Ring.rtf Get to know them / Invite them home Get to know them / Invite them home

26. Observation & feedback is key: Videos Videos Joint surgeries Joint surgeries Sitting in Sitting in Address issues directly Address issues directly Emphasise no need to prove medical knowledge Emphasise no need to prove medical knowledge

27. Key tutorials Early: Role of GP, patient expectations, health seeking behaviour Early: Role of GP, patient expectations, health seeking behaviour Ethics Ethics Sexuality, death etc Sexuality, death etc Non medical consultations Non medical consultations Explaining common conditions to patients Explaining common conditions to patients

28. Encourage trainee to Recognise and value patient centred consulting early Recognise and value patient centred consulting early Be curious about patient lives Be curious about patient lives Study group with non IMGs (to avoid collusion) Study group with non IMGs (to avoid collusion) Culture eg magazines, soaps Culture eg magazines, soaps Embed in team: social events, learn from all staff Embed in team: social events, learn from all staff

29. Resources http://www.londondeanery.ac.uk/var/lang uage-and-communication-resource-unit http://www.londondeanery.ac.uk/var/lang uage-and-communication-resource-unit http://www.londondeanery.ac.uk/var/lang uage-and-communication-resource-unit http://www.londondeanery.ac.uk/var/lang uage-and-communication-resource-unit http://www.londondeanery.ac.uk/var/inter national-medical-graduates/international- medical-graduates/?searchterm=img http://www.londondeanery.ac.uk/var/inter national-medical-graduates/international- medical-graduates/?searchterm=img http://www.londondeanery.ac.uk/var/inter national-medical-graduates/international- medical-graduates/?searchterm=img http://www.londondeanery.ac.uk/var/inter national-medical-graduates/international- medical-graduates/?searchterm=img http://www.londondeanery.ac.uk/var/lang uage-and-communication-resource-unit http://www.londondeanery.ac.uk/var/lang uage-and-communication-resource-unit http://www.londondeanery.ac.uk/var/lang uage-and-communication-resource-unit http://www.londondeanery.ac.uk/var/lang uage-and-communication-resource-unit http://www.londondeanery.ac.uk/var/inter national-medical-graduates/international- medical-graduates/?searchterm=img http://www.londondeanery.ac.uk/var/inter national-medical-graduates/international- medical-graduates/?searchterm=img http://www.londondeanery.ac.uk/var/inter national-medical-graduates/international- medical-graduates/?searchterm=img http://www.londondeanery.ac.uk/var/inter national-medical-graduates/international- medical-graduates/?searchterm=img

30. Summary Be aware of challenge Be aware of challenge Commit the time Commit the time Create the safest of environments Create the safest of environments Don’t shy away from addressing the issues Don’t shy away from addressing the issues