Clinical performance concerns

Medical training

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.

Work experience

Overseas

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).

In Australia

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.

Knowledge

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:

• history-taking
• physical examination
• investigations (ordering of and interpretation)
• management.

History-taking

Reasons for inadequate history-taking include:

• lack of attention to history-taking or inability to take a focused history
• language-related
  • 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.

Physical examination

Difficulties with physical examination include incomplete examination or poor examination technique.

Investigations

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).

Management

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

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).

Like any other individual, and particularly with increasing age, IMGs may become ill or have a disability. When a performance concern has been identified, it is important to consider the possibility of an underlying health issue. Any significant illness (physical or mental, acute or ongoing) has the potential to:

• affect judgement or performance
• impact on patient care
• impact on self, family and friends, colleagues and work capability.

Personal and family issues can also affect health and work performance.

Of particular note as regards personal issues:

• discrimination in society and in their professional practice can impact the IMG
• IMGs who are older, having spent a substantial part of their working life overseas, may be less adaptable and open to change, may struggle more with their learning (memory issues, health issues that impact on study time) and have a rigid or doctor-centred consultation style.

Family issues that occur commonly include:

• having to provide for family (which may be in Australia and/or overseas) and attending to family and their needs – commitment to the family’s needs generally takes precedence over other things, particularly when there are young children and/or elderly parents to take care of
• female IMGs, even if they are working part time, struggling to manage their daily responsibilities – situations of gender inequality only add to their difficulties.

Identity, self-esteem, self-confidence, expectations of self

Like any other migrant, there may be conflict for the IMG between their aspirations and expectations before coming to Australia and what they find and what they are able to achieve. A common scenario is the IMG who trained and worked as a specialist in their home country, and, having migrated, expects to work in that specialty. For many, the reality is that they have no other option but to work as a GP and this affects their identity and self-esteem.

Identify and self-esteem are also impacted by being a migrant in a foreign country, having inadequate English language skills, having to study and pass exams again when they are already qualified as a doctor and having restrictions placed on practice.

There may be conflicting notions regarding the role of the doctor and the role of the patient and how the interaction between them is conducted. This may manifest as difficulties with the patient-centred clinical method (as opposed to a doctor-centred model) and the notion of ‘equality’ in the consultation. This can have flow-on effects on such things as the provision of information and explanations, shared decision making and negotiation with the patient.

There may also be conflicting notions regarding the role of the doctor and the role of other staff. Problems can arise if, for example, the IMG adopts a position of superiority with respect to nurses and non-medical staff. If the IMG believes that their authority is being questioned, friction may arise, with the potential to create a hostile work environment.

The IMG may lack self-confidence and assertiveness in the clinical setting, which may manifest as difficulties with:

• interpersonal skills generally
• decision making
• managing difficult patient behaviour (especially drug-seeking behaviour)
• teamwork.

Personal cultural factors

The IMG’s personal values, attitudes and beliefs can sometimes create tensions, particularly as regards interactions with medical educators, supervisors and generally those who they perceive to be their superiors by virtue of learning, experience or social status:

• The educator is generally held in great esteem and the learner is not encouraged to question or challenge or in any way appear that they know more. The reluctance of IMGs to answer questions or give opinions in teaching sessions can therefore be interpreted as a lack of knowledge, interest or confidence, or an unwillingness to engage.
• From an IMG’s perspective, the educator’s role is to provide learners with all the material and information they require. When faced with differences in teaching style – such as experiential learning, problem-based learning and discussions – IMGs are at a loss as to how to participate effectively.
• Feedback, and especially negative feedback, may be perceived as criticism and may be accompanied by feelings of shame and loss of face.

Insight, ability to adapt and change

For IMGs, there may be difficulties with self-awareness, self-reflection, and recognising their limitations and learning needs. Consequently, the IMG may be unwilling or reticent to engage with supervision and remediation programs.

In general practice, the IMG’s ability to adapt and change is evidenced by the degree of adaptability to the different social norms and work culture, as opposed to the degree of fixedness to the traditional systems/methods to which they have been accustomed.

Difficulties with integration, socially and professionally, may impact on:

• quality of life
• education (experience and outcomes)
• professional and community networks (ability to communicate and interact with a range of people in different roles)
• workplace culture, interaction with colleagues and other health professionals.

Motivation

Motivation to learn, improve skills, and integrate in the workplace and the community is a personal thing. While for many IMGs the will may be there, the imperative to work and provide for family tends to take precedence.

Study and exams

Study can present many problems for IMGs, including:

• unfamiliarity with adult learning principles (textbook as opposed to experiential learning, being used to being told what to do and consequently not always being proactive with learning)
• limited time to study because of having to balance work and family commitments – commitment to family generally takes precedence over the need to study, particularly when there is lack of support with caring for children
• limited opportunities to attend continuing professional development (CPD) and exam preparation sessions, form study groups and engage with and learn from more-experienced GPs
• lack of mentoring/guidance (knowing what is expected and how to do it)
• lack of access to peer support, such as supervisors and mentors.

Work environment and systems are areas sometimes not considered as having an impact on clinical capability, but they are nevertheless important.

‘Work environment’ includes:

• employment contracts and conditions, such as working in an unsupported, high-demand clinical environment where IMG needs (in order to develop their skills and to study and pass exams) are not met
• practice systems, such as understanding and navigating the social, healthcare and medico-legal systems – these are of particular concern, given potential difficulties with understanding the Pharmaceutical Benefits Scheme, the Medicare Benefits Schedule and Schedule 8 regulations
• emotional intelligence, or lack thereof, in the workplace (which may also be related to notions regarding the role of the doctor and the role of others).

‘Systems’ include:

• various regulatory requirements, such as medical registration and limitations on practice (as imposed by the government and Medical Board)
• the requirements of the AMC and RACGP (including exam requirements).