1. Neena E. Thomas-Eapen, MD., FAAFP. Reema Menezes, MD., Bhavani Kundeti, MD. Suhail Alkilani, MD., Olabukola Olatunji, MD. UND Center for Family Medicine, Minot Department of Family Medicine UND School of Medicine and Health Sciences North Dakota, USA. Global Health Workshop, AAFP, Minneapolis, September 8, 2012

2. Speaker, Neena E. Thomas-Eapen, MD., FAAFP. or co-authors have no potential for conflict of interest with this presentation

3. International Medical Graduates: Statistics Strengths Weaknesses Challenges and positive effects of training and practice Biases Quality of care Lessons to learn Sharing and giving back globally

4. A group reflective paper

5. Blue Team Faculty, Neena Thomas- Eapen, M.D., India Residents, PGY1, PGY2, PGY3, All IMGs Minot USA Team Nurse, Kim Lakoduk, Minot USA PGY3, Olabukola Olatunji, MD., Nigeria PGY3, Reema Menezes, MD., India PGY3, Suhail Alkilani, MD., Syria PGY2, Bhavani Kundeti, MD., India PGY1, Sanju Mahato, MD., Nepal

6.  Foundation for advancement of International medical education and research(FAIMER)  ECFG data base and 2009 American medical association physician master file

7. Blue Team Neena, Faculty, India Residents, PGY1, PGY2, PGY3, All IMGs Kim, Nurse,USA Olabukola, PGY3, Nigeria Reema PGY3 India Suhail, PGY3, Syria Bhavani, PGY2, India Sanju, PGY1 Nepal

8. One quarter (24.8% or 50,804) of primary care physicians in the United States are IMGs. (1) Among all IMGs, 41.2% were PCPs compared to 32.8% for USMDs and 57.5% for DOs.(2) 1. Thompson MJ 1. Thompson MJ et al. J Rural Health. 2009 Spring;25(2):124-34J Rural Health. 2. Fordyce MA. et al., Family medicine, JUNE 2012 VOL. 44, NO. 6

9. Fordyce MA. et al., Family medicine, JUNE 2012 VOL. 44, NO. 6 In seven states IMGs represented more than 30% of the rural PCP workforce. Florida - 51.6% New Jersey - 41.8% Delaware - 38.7% New York - 35.5% West Virginia - 34.5% Maryland - 33.3% Illinois - 32.9%

10. Five states had less than 6% of PCPs as IMGs: Idaho -1.5% Vermont - 4.0% Colorado - 5.3% Alaska - 5.5% Montana - 5.7% Fordyce MA. et al., Family medicine, JUNE 2012 VOL. 44, NO. 6

11. Map date: August 2010. Sources: AMA and AOA master files Percentage of IMGs in the rural PCP workforce, 2005

12. Statistics from Education commission for foreign medical graduates(ECFMG); accessed August 2012

13. International citizen educated in an international merit based publically funded medical school Mostly from developing countries North American citizen ( US or Canadian) educated in a private medical school International citizen educated in a private medical school

14. IMG from merit based School The top students of education Weeded through highly competitive entrance exam and admission procedure Experience with high patient volume- excellent clinical skills IMG from a private medical school Varying criteria for admission process depending on the college Quality of teachers variable Patient volume and hence clinical experience highly variable North American IMG from a private medical school Varying criteria for admission process depending on the college Quality of teachers variable Patient volume and hence clinical experience highly variable

15. IMG from merit based School Problems: Language Culture – popular and medical System based practice IMG from a private medical school Problems: Language Culture – popular and medical System based practice North American IMG from a private medical school Problems: Much less clinical experience Varying quality depending on the medical school and the places of rotation

16. Medical knowledge from text books Clinical skills History and physical Experience with large volume of patients of diverse pathology Strong base for infectious diseases Experience with many procedures Hard working Disciplined

17. Communication Staff Patients Family IdiomsAccentSlangs Street language Medical language Nonverbal gestures Facial Expression s Speaking slow, clear and loud

18. Independent decision making Reliance on hierarchal etiquettes Ancillary services: Social services, Rehab services Physical therapy Occupational therapy End of life decisions, Code level, hospice care, family meetings Patient autonomy Privacy HIPPA Alternate care facilities Nursing homes Assisted living Adult foster care

19. Critical care and procedures in ICU PsychiatryRheumatologyDermatology Continuity of care in Obstetrics Evidence based chronic disease management Communicating with specialists Reliable point of care medical recourses Professionalism in North American medical culture Dermatology in the context of American population Electronic health records

20.  Every country trains their doctors for their needs with the available resources.  There is great disparity and variation between countries and training.  However the basics of modern medicine are the same throughout the world.  We just have to make sure they have a good basics (USMLE, ECFMG).  Train them to adapt to new medical culture and to become global health leaders.

21. ObservershipsLenient visa policies Leniency in graduation date Focus on continuity of clinical experience Give credit to the international advanced training after basic medical degree So that we maximize the number of good physicians in the system

22.  Preparatory programs  Orientation  PGY1 Support group  PEER Mentoring Program  Train-the-trainer programs for faculty  Use the experience and wisdom of IMG faculty (sometimes underused)  Cultural Diversity picnics/ potluck/ retreats  Global Health Interest International health electives.  Medical education and graduate training must adapt to the change

23.  Helpful Tips  Resources to improve their pronunciation and accent reduction  Early exposure in training to nursing homes, assisted living, and workshops  Early demonstrations on mannequins on procedures not commonly done (Women’s Health series, Procedure Series) and competency tests at regular intervals  Presentation by various ancillary staff(Social Service, OT/PT, Pharmacy, Nursing) on community resources and guidelines to follow.  Give clear and immediate feedback that is not critical but conducive to learning.  Foster an inclusive welcoming climate  A genuine interest in the previous training and their skills

24.  It takes time for IMGs to change to a new education and medical practice system  A good, long orientation is the effective key  Needs continued reaffirmation  Utilize the IMG faculty effectively building upon their experience

25. In 2006, ECFMG launched the Acculturation Program to assist IMGs who plan to enter U.S. training programs with the transition to training and living in the United States.

26. Financial and social challenges Personal and emotional hardships (differences in culture, education, and health care systems) Insensitivity and isolation in the workplace (Spans a wide range cultural misunderstandings to frank discrimination) Navigation of dual learning curves as immigrants and as residents Jobs or fellowships may be difficult IMGs’ migration has personal and global costs

27.  Every resident learns the system over the course of 3 years.  Some faster  Some slowly, but surely  The molding and mentoring and time spent are worth  Ultimately, IMGs make up a major percentage of primary care work force

28. one-quarter of the physicians - 25.3 % one-quarter of resident physicians 27.8 % serve in the neediest communities 30 % of the work force in primary care specialties. care for the uninsured and the indigent populations in inner city Care for the rural population Many in teaching and research Brings ethnic and cultural diversity in medicine in this era of globalization Adds variety to the pool of caregivers. IMGs Decreased Interest for U.S medical Graduates to serve

29. Care and mortality for CHF and MI in Pennsylvania, U.S – Comparison of IMGS and US graduates : No statistical difference Fewer in-hospital deaths among the patients of non-U.S.-citizen IMGs Vs patients of either U.S.-citizen IMGs or U.S. graduates. Norcini et all Health Aff (Millwood). 2010 Aug;29(8):1461-8.Health Aff (Millwood).

30. * Loss for the parent country – short term, long term, financial, gifts and talents. * Gain for the receiving country – North America/ Europe/ Australia and other developed countries of the world

31.  Life situations – marriage, difficult situations, education  Better living conditions  Better pay  Better work environment  Better research facilities  Advanced facilities  Stability of the country  Better future for children

32. It may be not that bad ! Can good things happen? Migration and quest for greener pastures have happened as long as human being have been on earth It depends on the demand and supply Our world has changed a lot with technology and advancement of science How can we make use of the migration and training of IMGs for betterment of health of the world?

33. Various opportunities TO HOME COUNTRY Individual contributions Through organizations * Clinical work – short term and long term * Education – population and educators * Policy and system changes LOCAL *Care of the immigrant and ethnic population *Free clinics *Health education *Other voluntary works GLOBAL HEALTH Individual contributions Through Institutions Through organizations *Clinical work – short term and long term * Education – population and educators * Policy and system changes

34. Transform “Brain Drain” to “ Brain Gain” For the betterment of all countries Fulfill our global responsibility to improve world healthcare

35. . Valuable asset for U. S/ North American medical system Benefit for their home country Advancement of global health IMGs A significant and growing segment of the physician workforce in U.S Brings the best from their educational background Refinement of their professional aspects Residency Time to establish critical elements Professional identityProfessional behaviors

36. IMG Resident Focus on their strengths Validate the valuable skills they bring in and build on it Understand the challenges Attending FP Opportunities to observe faculty and senior physicians during training Supportive strategies, mentoring, molding, reinforcement of expectations Utilization of the experience of IMG faculty Global Physician leader Culturally relevant, scientifically sound, Economical, health oriented, Whole person care addressing body, mind and spirit not only in North America, but also in their home countries and globally

37.  J Gen Intern Med. 2010 Sep; 25(9): 947-53. Epub 2010 May 26. J Gen Intern Med.  J Natl Med Assoc. 2005 Apr; 97(4): 467-77. J Natl Med Assoc.  J Gen Intern Med. 2004 Mar; 9(3): 259-65. J Gen Intern Med.

38.  Kimberly Lakoduk, LPN – Our wonderful team nurse for working with us attending to our various needs  Karen Anderson – Our medical librarian at the Agnus L. Cameron Medical Library, Minot. – for searches of articles  Dr. Subbekchha Aryal – for blue team picture  Paul Eapen, Tom and Asha Gilbertson – for helping with slides