Whether the IMG studied medicine in their home country or elsewhere, the education that they received is likely to have been subject-oriented, teacher-centred, discipline-based, lecture-focused and hospital-based.
The amount of work experience the IMG had before emigrating can be quite variable and it may have been in a different country from the country where they received their training. It may have been minimal, equivalent to internship only, or they may have worked for a number of years. Their work experience is more likely to have been hospital-based.
The IMG may have a specialist qualification in their country, but for various reasons has decided to pursue general practice in Australia. Not uncommonly, general practice is their only option because they are unable to gain registration to practise in their specialty in Australia.
If the IMG worked in general practice overseas, this would have been different to how it is practised in Australia (particularly in relation to GP autonomy, the scope of practice, different presentations, the patient-centred method, communication, gender relations and other sociocultural factors).
Before being able to practise in Australia, IMGs have to obtain medical registration and comply with certain conditions. At the very minimum, they have to have passed the AMC Part I (multiple-choice questions paper) and an English proficiency test. This will allow them to work in a hospital or in general practice in an area of need or district workforce shortage.
IMGs who have passed the AMC Part II (clinical exam) will probably have completed their intern year, as well as a year of residency, and then entered an AGPT Program. For various reasons, some do not complete their general practice training and are then in the same predicament as those who have only completed the AMC Part I.
IMGs may be working in a narrow field of practice and so their clinical experience is constrained. One example is after-hours or locum work, where the range of presentations is limited. Another example is when IMGs choose to work in a location where most of their patients are from their own community. While this has its advantages (eg common language, a closer understanding of the needs of their patients, the ability to address patient concerns more readily), it constrains IMGs from gaining broader experience and a better understanding of Australian general practice. This becomes problematic when IMGs find themselves in a different context and have to adapt to mainstream general practice and meet the expectations of AMC and RACGP examinations.
Generally speaking, IMGs have very good book knowledge, but some have knowledge deficits that impact on clinical capability. Factors that contribute to those knowledge deficits include:
- limited clinical exposure
- the individual’s motivation to study (inability to pass exams can be one of many reasons behind the lack of motivation)
- family concerns, which may take precedence, distracting the IMG from studying or creating difficulty in allocating regular study time
- the individual’s ability to learn:
- being older and having difficulty studying efficiently, and memory not being as sharp
- being more inclined to learn facts than develop problem-solving skills
- relying on limited study methods (eg rote learning, preference for instructional teaching and direction)
- using limited learning resources (eg preference for factual sources, such as textbooks)
- finding it difficult to form study groups (eg not knowing who to connect with, remoteness of location and consequently limited access to study partners, internet connectivity issues).
Language and communication skills
Language refers to both the spoken and written word. It is the ability to express oneself as well as the ability to be understood. In the clinical context, communication skills refers precisely to those skills required to communicate effectively in conducting a consultation. It is important to delineate what constitutes difficulty with language and difficulty with communication skills.
Language difficulties include:
- verbal skills:
- command of English – pronunciation, accent, vocabulary, fluency, contextual meaning
- thinking–translation processes – ‘thinking in their language’, translating the language and science of medicine into lay language
- understanding – the Australian accent; the patient’s pronunciation, intonation and use of idiom, slang and humour; nuances and cues
- non-verbal skills:
- body language
- written fluency (clarity with medical records, including referral letters).
Language skills may sometimes be observed to be weak in the clinical setting but not in a different context. Any difficulty with language will contribute to communication skills difficulties. This will generally manifest in the manner of communication – for example, the ability to choose the right words; knowing what is appropriate to say and do, without offending; and providing the necessary information clearly and succinctly.
These concerns about communication are not confined to IMGs. All doctors have to bridge the ‘cultural divide’ between doctor and patient. IMGs, however, have to contend additionally with the divide between their culture and the Australian culture. In other words, they need to accommodate the differing expectations about what constitutes appropriate communication, the roles of the doctor and patient in the consultation, and what is appropriate in the consultation. In some countries, for example, the practice is not to inform the patient about a fatal diagnosis or prognosis. This sits at odds with the Australian context, where the patient has a right to know. Medico-legal and ethical problems present significant dilemmas to IMGs regarding what is and isn’t appropriate.
General consulting skills
It is frequently observed that the IMG consultation is not well structured and time management is poor. This will generally be due to difficulties with one or more of the elements of the consultation:
- physical examination
- investigations (ordering of and interpretation)
Reasons for inadequate history-taking include:
- lack of attention to history-taking or inability to take a focused history
- inability to make precise word choices so that the patient may understand the doctor’s intentions
- having been trained in a more interrogative form of history-taking and therefore having difficulty using open-ended questions
- not knowing how to phrase a question out of fear of offending
- knowledge-related – for example, being unfamiliar with psychosocial issues, and consequently not knowing how they might relate to the presentation or how to explore those issues.
Difficulties with physical examination include incomplete examination or poor examination technique.
Issues with investigations are generally with respect to:
- over-reliance on investigations in the problem-solving process, because of inadequate history-taking and/or physical examination
- difficulty with the interpretation of test results – a factor may be that terminology and interpretation of results can differ between countries
- not knowing what to do with abnormal results (especially false positives).
In the management phase of the consultation, difficulties will generally occur with:
- developing an individualised, holistic management plan
- a tendency to be concerned with management of the presentation and not looking more broadly for associated issues or, if they have been identified, not addressing them
- long-term management plans being formulaic rather than tailored to the individual and the context
- delivering the management plan and providing information and explanations clearly and succinctly
- involving the patient in the management (shared decision making, negotiation).
Clinical reasoning occurs in all phases of the consultation. This fundamental skill is frequently a weak point for IMGs. There are several contributory factors:
- jumping to conclusions
- a tendency to think in ‘black and white’ and consequently struggling with managing uncertainty
- a tendency to focus on making a diagnosis
- discomfort with problems where the diagnosis and/or solutions are not clear-cut or do not fit ‘what the textbook says’
- difficulties in problem solving.
Even though their knowledge base may be good, IMGs may have difficulties with their application of knowledge. This usually manifests as a mismatch between demonstrated clinical skills and knowledge and/or difficulties with clinical reasoning.
Social and medico-legal issues
Social and medico-legal issues include being unfamiliar with ethical practices, the law and other regulations, which may result in patient complaints and reporting to the Australian Health Practitioner Regulation Agency (AHPRA). They can manifest in:
- crossing doctor–patient boundaries because of unwittingly using inappropriate language or inappropriately touching (not knowing the right words, not knowing the social norms, not knowing what is appropriate in a particular context)
- not knowing what constitutes informed consent
- not complying with the regulations regarding patient confidentiality
- inappropriately prescribing drugs of dependence because of not knowing the regulations around them
- having inadequate documentation (medical records).