1. International Medical Graduate trainees Bradford Trainers Workshop 12 5 2010 Maggie Eisner

2. Session plan Sharing experiences of IMGs – Amanda Nix IMGs and the CSA – Louise Riley The IMGs point of view How can trainers and the training scheme best support IMGs?

3. Sheffield IMG survey Sent to Sheffield IMGs in 2009 Headings under nMRCGP competencies Also sent to educators 42 full responses Report includes comments by many others to whom initial responses were sent Full report on Deanery website

4. Communication The biggest issue by miles! Underlies many of the other problem areas Language and culture interlinked but useful to consider separately

5. Communication - language Colloquialisms Pronunciation and accents – both the doctors and the patients Difficulty with humour Learning stock phrases is of limited use - may sound formulaic and insincere doesnt help doc adapt language to patient Non verbal and para verbal (e g intonation) skills also important

6. Communication - culture IMGs (like all hospital doctors) may have difficulty explaining their thoughts and plans to patients NB – not confined to IMGs – like many of the difficulties, applies to any doctor and patient communicating across language and cultural barriers

7. Working with colleagues Cultural differences important (medical and social culture) Most IMGs come from more hierarchical medical culture – adapting to ours may be uncomfortable, with disorientating sense of loss of role Forms of address may cause discomfort (on both sides) Cultural learning should be 2 way – it is as important for team to understand IMGs culture as vice versa. We are all ambassadors for our culture – colleagues behaviour has great influence on how we perceive and interact with others from the cultures they represent.

8. Holistic approach Not true that IMGs dont understand a holistic approach – but theirs is in different social context (extended family system) Psych illness stigmatised in some cultures, may make doctors reluctant to explore Fee paying health service in home country may make Dr reluctant to waste patients time discussing psychosocial stuff Biomedical -> holistic shift also experienced by UK trained docs moving from hosp to GP

9. Clinical management Different approaches determined by patient expectations the doctor is used to, or range of management options available Incidence of different conditions in different countries, implications of same sympts and signs (e g fever in tropics and in UK) Cultural communication factors may create clinical management problems if sensitive issues need to be discussed (esp male Dr and female pt)

10. Medical complexity Hard for all trainees (? and trainers) to grasp at first IMGs may find it especially hard because of lack of experience earlier in career of managing elderly patients with many co morbidities NHS type primary care system Idea of health promotion as integral to GPs work

11. Professionalism Values vary between cultures, including ethical values underlying professional codes like Duties of a doctor Apparently unprofessional behaviour can reflect lack of familiarity with current UK professional codes and the values underlying them

12. Teaching methods Student-teacher relationship differs between cultures. Most IMGs used to expectation that teachers should be respected unconditionally and not challenged Concept of self directed learning AND skills needed for it may be unfamiliar NB – all learners have individual learning styles; educational culture IMGs have come from is only one factor you need to know to design an appropriate teaching programme

13. IMGs on Bradford STS Currently 12 (11 Indian subcontinent, 1 EU) 3 meetings in 2010, ½ day at HDR and 2 full days at Broughton Hall Found out about their point of view – all felt that communication is most important issue Discussed areas of concern Discussion and role play about difficult communication areas – sex and death Watched London Deanery video

14. Helping IMGs - principles Start early Be aware of challenges faced by IMGs Respect them – dont see them as a problem IMGs in difficulty may need multifaceted support (trainer, ES, TPD)

15. Helping IMGs – encourage to Recognise and practise pt centred consultation skills (ICE, looking for cues, sharing options) early Be curious about patients lives, ask about them in consultation Self assess on competencies early, and understand what they mean Observe experienced colleagues consultations Get involved in informal aspects of practice life Watch TV soaps with local accent (Emmerdale), read newspapers Get involved with English social groups Try to speak English at home

16. Helping IMGs – trainers – at the beginning Get to know them as a person as early as poss, show interest in their background, ? Invite them home Team social activity early in their attachment Go out/sit in with different team members Early tutorial on practice patients help seeking behaviour, perceptions of GP, role of GP in NHS Assess their English (speaking, listening, reading, writing); plan to address language needs Explore their learning style and educational background in order to plan your approach to their training

17. Helping IMGs – trainers Tutorials about cultural/linguistic aspects of Care of the elderly Death, bereavement, care of the dying Sexuality, sexual behaviour, sexual health Tutorials on ethics and professionalism, sharing dilemmas and areas which might be dealt with differently in different cultures Lots of video and role play Lots of feedback (more than UK graduates) To give confidence and encouragement To identify learning needs