1. Addressing the Training Needs of International Medical Graduates Anjla Sharman PD Equality in Training

2. Objectives Consider data relating to IMG exam pass rates. Examine the research looking at why IMGs struggle in training. Discuss strategies that may be helpful in supporting IMG trainees.

3. National pass rates in AKT and CSA in 2010-11 AttemptPass Rates (%) AKTPass Rates (%) CSA UK Grad Non-UK Grad UK Grad Non-UK Grad 186.654.491.840.8 27050.382.837.6 366.757.45028.7 445.548.637.524.3

4. Demographics of EMHWD Trainees Sitting AKT & CSA UK Grad Non-UK Grad AKT12196 55.8%44.2% CSA9961 61.9%38.1%

5. Research evidence (US) Less likely to consider patients as equals, Not been trained to talk patients through an examination Not trained to explain illness, medical procedures or prognosis to patients. Less knowledge re the psychosocial aspects of illnesses Less used to self-directed learning. Linguistic issues (including accents)

6. Research evidence (Australia) Difficulties adjusting to Western culture Reactions to separation from extended family and friends. Difficulties adjusting to Anglophone ‘medical culture’. New patterns of disease. IMGs have to cope with changes in self-esteem and differences in learning styles. Language and communication issues.

7. Research evidence (York and Humber) Communication – both linguistic and cultural contexts Working with colleagues Differing views re holistic approach (psychosocial aspects of healthcare) Patient centred care Differences in ethical approach to practice

8. Research evidence: GMC 2009 Many IMGs find there are major differences in the ethical frameworks of their country of training and in the UK. In particular the greater emphasis on autonomy, duty of confidentiality and informed consent may come as a surprise. The GMC has recommended increased training and support around ethics alongside clinical practice.

9. Main Areas of Challenge Cultural competence Linguistic competence NHS and new systems Status as doctors Self directed learning Knowledge gaps as new patterns of disease Differences in medical ethics Reflection Psychosocial aspects of care Patient centred care –ICE –Shared management –Explanations Teamwork

10. Small Group Activity Split into groups of 4-5. Consider the main areas of difficulty that IMGs encounter in training. Discuss each area and formulate three strategies that could be used to support IMGs.

11. Understanding the Consultation Teaching on reflection can improve AKT outcomes: Control group - 32.5% pass rate Intervention group – 60.6% pass rate

12. Final thoughts... It’s not just IMGs who struggle... In 2011 a meta-analysis published in the BMJ showed that there were differences in academic performance in both UG and PG assessments in UK trained doctors from ethnic minorities. Potentially a significant issue for the East Midlands:

13. Ethnicity of EM Trainees Sitting the AKT and CSA ExamEthnic Group White South Asian Black Chinese/ SE Asian Mixed Race/ Other Not Known AKT 7311817270 33.6%54.4%7.8%0.9%3.2%0 CSA 558610351 34.4%53.8%6.3%1.9%3.1%0.6%

14. Bibliography MRCGP: Statistics 2010-11.Annual report(Aug 2010 to July 2011) on the results of the MRCGP AKT and CSA Assessments. Richard Wakeford. Available at: http://www.rcgp.org.uk/gp-training-and-exams/mrcgp-exam- overview/~/media/Files/GP-training-and- exams/Annual%20reports/MRCGP%20Statistics%20201011%20draft%20at %20071111.ashxhttp://www.rcgp.org.uk/gp-training-and-exams/mrcgp-exam- overview/~/media/Files/GP-training-and- exams/Annual%20reports/MRCGP%20Statistics%20201011%20draft%20at %20071111.ashx General comments about features/behaviours observed in passing and failing candidates in the CSA. RCGP. Available at: http://www.rcgp.org.uk/gp-training-and-exams/mrcgp-exam- overview/~/media/Files/GP-training-and-exams/General-comments-about- features-behaviours.ashx http://www.rcgp.org.uk/gp-training-and-exams/mrcgp-exam- overview/~/media/Files/GP-training-and-exams/General-comments-about- features-behaviours.ashx Singhal K and Ramakrishnan K (2004) Training needs of international medical graduates seeking residency training: evaluation of medical training in India and the United States. The Internet Journal of Family Practice Pilotto LS, Duncan GF and Anderson-Wurf J (2007) Issues for clinicians training international medical graduates: a systematicreview. Medical Journal of Australia 187: 225–8.

15. Rughani, A. and Davangere, A. (2010) Curriculum evaluation focused on the experience of IMG trainees in Yorkshire and the Humber Deanery. Available at: http://www.yorksandhumberdeanery.nhs.uk/general_practice/IMGs/ http://www.yorksandhumberdeanery.nhs.uk/general_practice/IMGs/ Slowther, A., Lewano Hundt, G., Taylor, R. And Purkis, J. (2009) Non UK qualified doctors and Good Medical Practice: The experience of working within a different professional Framework. Report for the General Medical Council Available at: http://www.gmc- uk.org/FINAL_GMC_Warwick_Report.pdf_25392230.pdfhttp://www.gmc- uk.org/FINAL_GMC_Warwick_Report.pdf_25392230.pdf Ethnicity and academic performance in UK trained doctors and medical students: systematic review and meta-analysis. K Woolfe, HWW Potts, IC McManus. Available at: http://www.bmj.com/content/342/bmj.d901.pdf%2Bhtmlhttp://www.bmj.com/content/342/bmj.d901.pdf%2Bhtml