A guide to understanding and managing performance concerns in international medical graduates

Understanding IMGs

Last revised: 19 May 2020

IMGs, like other migrants, have to adjust to a different way of life and to a social system and behavioural norms that conflict, to varying degrees, with their personal and ethnic values. Perceptions of IMGs can sometimes be misguided, with prejudice and bias directed against them and their families.

IMGs face significant pressures, perhaps more so than the average migrant. They have constraints placed on them with respect to their medical registration and where they are allowed to practise; consequently, they may feel trapped. Their identity is challenged and their self-esteem may be affected because they have to study and pass exams all over again in order to prove themselves capable and competent. Many lack appropriate support and guidance and find themselves struggling to pass exams and to achieve the requisite standard of practice.

IMGs are often misunderstood and a disservice is done to them when it is rationalised that their difficulties are entirely due to a ‘lack of knowledge’, ‘cultural’ factors or ‘language’ issues. Certainly, these are important considerations, and while generalisations can sometimes be useful, great care needs to be exercised because IMGs are a disparate group.

Hofstede’s six dimensions of national culture (Appendix A) is a useful framework for comparing cultures and providing insight into the values and behaviour of IMGs. However, care needs to be exercised because the framework relates to values of ethnic cultures, not individuals.

As regards clinical performance, the issues that IMGs contend with relate primarily to:

  • medical training and work experience overseas
  • language and communication skills
  • migration and displacement issues.

Depending on their circumstances, IMGs may or may not have trained or worked in their home country. Many IMGs have undergone specialty training and may have worked in their specialty field for a number of years before migrating to Australia. IMGs have to adjust to a very different health system and method of practice. Even if they have worked in general practice overseas, that context may be very different from general practice in Australia.

The aspects of general practice that IMGs have particular difficulty with are the:

  • different patterns of disease and clinical presentations (especially the early presentation of illness and psychosocial problems)
  • patient-centred clinical method, including patient education and shared decision making
  • medico-legal system (regulations, legislation, ethical dilemmas, medico-legal aspects of practice).

Communication is a fundamental skill in medical practice and difficulties with communication will impact on the outcomes of the consultation.

While IMGs are obliged to pass a proficiency test in English, this doesn’t necessarily equate to being able to communicate effectively in the consultation and the broader medical context. Even between English-speaking countries there are differences in the way English is spoken and understood, including differences in meaning, idiom, nuance, verbal and non-verbal cues, what is and isn’t appropriate to say in a given context, and social norms. IMGs will frequently identify these aspects of language as being problematic, as opposed to such things as limited vocabulary and difficulties with syntax.

Some IMGs continue to think in their own language, rather than in English. The result is that they continually translate in their mind from one language into the other, which can cause them to lose focus with respect to the task at hand.

Migration and displacement issues are not just related to arriving in a new country and having to adjust to a new way of life. The issues have deeper roots and relate to their life circumstances in their home country and the reasons for migration. They may be refugees who have endured hardships, perhaps even trauma, whose lives have been under threat and who have made difficult journeys to get here and who may be lucky to be alive. Having arrived here, their imperative is to work and provide for their families here and/or overseas. Being professionals, they are looked up to by their family and their community and have to meet their expectations. They have to provide for their family, including any particular needs related to health or disability. Moreover, their family may be separated from them. The IMG may be working in a rural location while their family is in the city, or their family may still be overseas.

IMGs have to balance competing pressures: work, family and study to pass exams – the Australian Medical Council (AMC) clinical exam and/or FRACGP. Many struggle to pass the exams, even though in some instances they have received support. There are many reasons for this; fundamentally, IMGs need to understand the role of a general practitioner (GP) in Australia. They need to learn the requisite skills for conducting a patient-centred consultation, managing chronic complex problems and psychosocial problems, and understanding medico-legal issues. Medical educators are certainly able to assist IMGs with these matters, but also need to be cognisant of all the different issues that IMGs contend with, and have strategies for addressing those issues.

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