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Medical Teacher

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International medical graduates and generalpractice training: How do educational leadersfacilitate the transition from new migrant to localfamily doctor?

Susan M. Wearne, James B. Brown, Catherine Kirby & David Snadden

To cite this article: Susan M. Wearne, James B. Brown, Catherine Kirby & David Snadden (2019)International medical graduates and general practice training: How do educational leaders facilitatethe transition from new migrant to local family doctor?, Medical Teacher, 41:9, 1065-1072, DOI:10.1080/0142159X.2019.1616681

To link to this article: https://doi.org/10.1080/0142159X.2019.1616681

Published online: 19 Jun 2019.

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International medical graduates and general practice training: How doeducational leaders facilitate the transition from new migrant to localfamily doctor?

Susan M. Wearnea , James B. Brownb� , Catherine Kirbyb� and David Snaddenc

aAcademic Unit of General Practice, Australian National University, Canberra, Australia; bEastern Victoria General Practice Training,Churchill, Australia; cNorthern Medical Program, University of British Columbia, British Columbia, Canada

ABSTRACTObjectives: To document medical educators’ experience and initiatives in training international medical graduates (IMGs) tobecome general practitioners (GP).Design: Qualitative social-constructivist emergent design with descriptive and interpretive analyses.Setting: GP vocational training in Australia, Canada, Ireland, New Zealand, the Netherlands, and UK.Participants: Twenty-eight leaders of GP training.Intervention: Data collected from public documents, published literature and 27 semi-structured interviews.Main outcome measures: Tensions in training and innovations in response to these tensions.Results: Medical educators identified tension in teaching IMGs as it could be different to teaching domestic graduates inany or all aspects of a training program. They felt an ethical responsibility to support IMGs to provide quality health care intheir adopted country but faced multiple challenges to achieve this. They described initiatives to address these throughoutGP training.Conclusions: IMG’s differing educational needs will benefit from flexible individualized adaptation of training programs.

Introduction

Many high-income countries rely on international medicalgraduates (IMGs) for their health workforce (Aluttis et al.2014). However, the symbiosis of a health care need, andIMGs’ willingness to migrate does not necessarily lead toan easy transition (Durey, Hill et al. 2008; Chen et al. 2011;Terry et al. 2014). There are tensions and challenges fordoctors, their colleagues and patients (Woods et al. 2006;Triscott et al. 2016; Skjeggestad et al. 2017; Davda et al.2018; Najeeb et al. 2018) especially when IMGs fill vacan-cies in under-served areas where patients often havehigher clinical needs and fewer personal resources[Australian Institute of Health and Welfare (AIHW) 2017].

IMGs are known to have lower pass rates in postgradu-ate examinations than doctors who complete medical andspecialist qualifications in the same country (Andrew 2010;Esmail and Roberts 2013). (Falcone and Middleton 2013;O’Neill et al. 2016) and, those from some countries, are athigher risk of malpractice claims (Dyer 2009; Elkin et al.2012; Jeyalingam et al. 2018). In Australia, IMGs studyingoutside the training program have lower exam pass ratesthan IMGs on the Australian General Practice TrainingProgram (Hoffman 2015).

Educators now recognize the stress and challenge oftransitions from student to junior doctor to consultant(Teunissen and Westerman 2011) and are researching howto facilitate these changes (Schumacher et al. 2012). Interms of transitions, IMGs often experience a series ofobstacles in a labyrinth to independent practice (House of

Representatives Standing Committee on Health and Ageing2012) and arguably could face bigger transitions whenmoving from one country to another (Harris andDelany 2013).

Doctors who want to become general practitioners (GPtrainees) learn by working in general practice under thesupervision of experienced GPs (GP supervisors) who areaccredited for teaching (Wearne et al. 2012). GP traineesalso require experience of GP relevant hospital specialties

Practice points� IMGs’ pass rates in specialty medical examinations

are known to be lower than doctors who com-plete medical and specialty training in thesame country.

� IMGs enter postgraduate specialty training in gen-eral practice with varied backgrounds, skillsand experience.

� Educators have innovated to assist IMGs at allstages of training, and report IMGs often needlonger in training to achieve qualifications.

� Offering all doctors a standardized training pro-gram is potentially inefficient and sets up manyIMGs to fail.

� Training programs, educators and GP supervisorsneed flexibility to individualize training in orderto produce equitable outputs of training.

CONTACT Susan M. Wearne susan.m.wearne@gmail.com PO Box 2681, Alice Springs, NT 0871, Australia.�These authors are also affiliated with School of Rural Health, Monash University, Churchill, Australia.� 2019 Informa UK Limited, trading as Taylor & Francis Group

MEDICAL TEACHER2019, VOL. 41, NO. 9, 1065–1072https://doi.org/10.1080/0142159X.2019.1616681

and must pass qualifying examinations. GP training pro-grams oversee GP trainees’ clinical placements and providean educational program of workshops and learning resour-ces (Michels et al. 2018). Being part of a program is com-pulsory in some countries whereas in others GP traineescan complete the training requirements independently.IMGs compete with domestic graduates to enter formaltraining programs. In Australia and Canada, training isoffered in exchange for doctors working in under-served,usually rural areas.

When IMGs undertake GP training, they join systemsand programs designed for that country’s domestic gradu-ates. IMGs may encounter a range of challenges to success-fully engage with these systems and programs. In order tosupport IMGs undertaking GP training, GP supervisors andtraining organizations need to understand and create waysto address them. This research explores these challenges ofsupporting IMG GP trainees. We set out to identify the ten-sions faced in IMG training and how leaders of GP educa-tion innovate to facilitate IMGs’ transition to qualificationfor independent general practice.

Methods

Overview

This research was part of a larger project examining thecurrent tensions and innovations in GP vocational trainingin Australia informed by international experience. Theresearch was conducted from the constructivist positionthat “the reality we perceive is constructed by our social,historical and individual contexts” (Kuper et al. 2008). Thisstudy is based on qualitative interview data. We reviewedthe Australian and international literature and publiclyavailable documents regarding GP vocational training. Thisreview informed our direction of enquiry, our choice ofinternational countries and interview guides. We chose fivecountries to expand on our Australian data. Canada,Ireland, the Netherlands, New Zealand, and UK wereselected for their similarity to the Australian approach toGP training and for their innovation.

Sampling

Sixteen expert informants from 14 Australian GP trainingstakeholder organizations were recruited by purposefulsampling to achieve broad representation. Following con-sultation with the reference group, we approached theleaders and leading medical educators of the nineAustralian regional training organizations (RTOs), the twoGP colleges (Australian College of Rural and RemoteMedicine (ACRRM) and the Royal Australian College ofGeneral Practitioners (RACGP), General Practice SupervisorsAustralia, General Practice Registrars Australia, and Leadersin Indigenous Medical Education.

From each of the five selected other countries, werecruited one national leader of GP training and at leastone regional leader of GP training either by direct contactto the national organization or via personal contacts of theresearchers or reference group. The total of 12 internationalinterviewees came from 10 international organizations. Two

international interviewees chose to be interviewed togethermaking a total of 27 interviews.

Recruitment

Potential participants were emailed information about theproject and invited to nominate times for telephone, video-conference or face-to-face interviews which would berecorded. Interviews were conducted between September2017 to February 2018, lasted up to 60min, were recordedand transcribed verbatim. Two experienced qualitativeresearchers conducted the interviews and anonymous ver-batim interview transcripts formed the data set.

Reference group

We established a reference group to guide this researchand facilitated six workshops with GP supervisors and med-ical educators. The reference group included: representa-tives from two of the Australian RTOs, ACRRM, the RACGP,and the Australian Department of Health. These groupshelped direct our approach and gave feedback on our ana-lytic direction and interpretations.

Interview guide

The interview guide was derived from topics identifiedfrom the literature review, workshops, and from the refer-ence group. The guide was piloted by the interviewers andrefined by them as the interviews progressed. We askedopen ended questions with a focus on tensions and inno-vations in training.

Analysis

The research team iteratively analyzed concurrently withdata collection (Charmaz 2014). We used an interpretivelens, drawing on the expertise of the research team(Cresswell 2013) (see Box 1), to identify tensions and areasof effective practice. Interviews were shared betweenauthors and analyzed separately to develop a codingframework and to enhance rigor. Coding was managedwith NVivo software (QSR International, Doncaster, Victoria,Australia). Themes were derived from the coding frame-work following frequent reading of the data and team dis-cussion. Findings and interpretations were discussed withthe reference group and meetings of medical educatorsand GP supervisors to ensure authenticity. The interviewswere numbered and labeled A (Australian) or C (Canadian),I (Ireland), N (Netherlands), NZ (New Zealand), and UK(United Kingdom).

Box 1.

SW: GP in Canberra and Alice Springs, academic at AustralianNational University, working in health policy.

JB: GP supervisor and senior medical educator in rural Victoria.

DS: Professor of Family Practice and Rural Doctors’ UBC Chair inRural Health, University of British Columbia.

CK: Senior general practice education researcher with postgraduatetraining in psychology.

1066 S. M. WEARNE ET AL.

Ethics

Ethics approval was gained from the Monash UniversityHuman Research Ethics Committee project 10033.

Results

Participants identified that teaching IMGs was challengingbecause of the IMGs’ diverse backgrounds and clinicalexperience. As educators, they felt an ethical obligation tofacilitate IMGs transition to providing quality general prac-tice. This required program flexibility to tailor support andeducation to meet individual IMGs needs.

Tensions: recognizing difference not deficits

Participants’ experience was that IMGs brought a widerange of skills across all aspects of the GP training. “Theirdrivers are different; their issues are different. You know, com-munication, understanding systems, the nuances of relation-ships with patients” [A06].

Participants felt strongly that the focus should be on dif-ference not deficit. Labeling IMGs as having learning needswas unfair without also acknowledging their strengths, andthe fact that many IMGs brought expertise that local grad-uates did not have. “Some of our international medical grad-uates who have come from countries where they wereextremely poor, they’ve seen extreme poverty … you know,some of our doctors that come from Pakistan, Afghanistan,Iraq. You know, all of those kind of countries. Particularly,they get this … they get health equity, they get deprivation,poverty, and being a doctor in those environments” [NZ1].Differences were noted individually and at a system level.

Individual differencesParticipants first mentioned language, communication, andcultural safety as key fundamentals that they had expectedwould need focus. Also strongly expressed was the topic of“professionalism”. This umbrella term was used to describea vital part of practice, but which was itself difficult todefine “the things like professionalism, for whatever thatmeans and empathy and those kind of things” [A06]. Thesewere soft skills that were key to effective clinical practice,but hard to teach. There was uncertainty whether a uni-form approach was even desirable. “Those areas that arereally challenging and we have a large registrar group thatcome from diverse backgrounds with different ideas. Theyobviously have different backgrounds and different levels ofunderstanding and what those things mean to them and soit’s a really challenging area. I don’t know whether I wanteverybody coming out being exactly the same because I thinkpeople should be allowed to have their individuality but anunderstanding of what those things mean within acommunity” [A09].

System differencesSystem and cultural differences were apparent not just ingender and societal roles, but in how power is used in clin-ical consultations. “Our American doctors, theystruggle… They’re not passing our clinical and written… Ithink our way we practice General Practice here is much

more community. Theirs is much more hierarchical” [NZ1].The system differences meant that IMGs had differentexpectations of their role, which in turn created more workfor educators as they helped them adjust to a new context.“I think there are different approaches and I’m trying to thinkof how to generalize of course but I think if you come from adifferent health system and if you’ve done your undergradu-ate training in a different health system, if it differs signifi-cantly then or if you’ve just been raised as a person in adifferent system you have different expectations. So yes, Ithink there is more work to be done with people from differ-ent health systems than from our own” [I2].

Educational differencesThere were further differences in what and how IMGs hadlearned during their earlier training “we find that the qualityof their training varies a great deal from probably betterthan ours to really worse” [C1]. Clinical reasoning was a par-ticular issue “Clinical reasoning in general practice is differentto other specialties and it’s really getting the IMGs in particu-lar, getting their head around the fact that general practiceisn’t easy, it’s really challenging and so you’ve really got tothink like a GP” [A16].

Motivations and rewards in assisting IMGs

Participants found teaching IMGs different to teachingdomestically trained doctors. They puzzled over how bestto support IMGs and while they were aware that this was ashared international challenge, with much to learn fromeach other, this has not yet happened: “many countries aregrappling with this and we’re doing as much as we can totry and help them, but I think it would be fair to say that weare aware that it is harder for them to get to the same pointat New Zealand trained doctors” [NZ2]. Participants aimedto train high quality GPs to serve the community, whowere “… fit for purpose doctors in terms of having theattitudes, the behaviors and the skills to meet the needs oftheir communities” [A19].

This aim was in tension with regulations in New Zealandand Australia which enable IMGs without formal GP qualifi-cations to work as GPs. “I don’t know of many profession inthe world… that you can call yourself a professional, withouthaving achieved an appropriate qualification. Why can youcall yourself a general practitioner when you have notachieved the fellowship standards of either College?” [A10].Educators felt obliged to address this inequity by givingIMGs more support especially as IMGs often worked in iso-lated rural and remote areas, with limited peer support.“The general public has a right and needs to know that theyare receiving safe, quality care from the doctor who is thereworking as their GP” [A15]. This ethical obligation to trainbrought intrinsic rewards when IMGs passed their GPexams “a lot of them have come as you know from a systemthat is so different and then they’re put in relatively isolatedareas, the odds are pretty much stacked against them sobeing able to support them and get them through I think isvery satisfying” [A19].

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Solutions

Just as IMGs needed specific knowledge, skills, and atti-tudes to practice effectively in their new country, so educa-tors of IMGs expressed the importance of appropriateknowledge, skills, and attitudes to teach them. Despite thetraditional order that attitude comes last on the list, gettingthis right was first priority.

Battling prejudiceParticipants were careful to counter prejudice or racismexpressed towards IMGs, arguing that stereotypes of themas unskilled, expressed in reluctance of GP supervisors towork with them, was unjustified. “We’re very aware of tryingnot to have preconceived ideas about anybody. We battlethat. You know, people say, “I don’t want an IMG” … whatdo you mean you don’t want? You know, what are you say-ing? Cos many are great”[Can 1]. “There are differences intraining international medical graduates but one mustn’t beprejudiced in it at all because many of them are absolutelyexceptionally good” [I1].

Selection and admissionsParticipants considered it important to select the right peo-ple for training. In Canada and Australia, the aim of offer-ing IMGs’ training in exchange for working in rural areas, isthat they will stay in that area once qualified. But the com-petition for training risks IMGs saying they are keen towork long term in rural, when in fact they are better suitedto and more keen on urban practice. “I think the mostimportant thing is just the screening and the admissions pro-cess—that they have the right fit for the program that theywant to go to. It’s very competitive, and they’ll kind of sayyes to anything. But in fact, it’s not true. Some are really wellsuited for rural practice, and some are not. And right now,they’re made to go, and they leave the minute they canleave, and it really doesn’t help the communities all thatmuch” [C1].

OrientationThe first knowledge to pass on to IMGs was clarity aboutthe health system and the role of general practitioners,which might differ from their previous experience “a lot ofthem have come as you know from a system that is so differ-ent” [A19]. Even those who had previously worked as GPsin their home country might need to make significantchanges to their practice and unlearn previous habits andnorms. “People also come from backgrounds where theyalready have a professional identity and how that fits what(GP training organization) sees as what you should look likeas a GP” [A09]. They needed a clear target that GP trainingwas not just about learning factual information eitheronline or via books, but was about developing the skills tohelp people. “If you do these series of online modules… -what you end up with is doctors that know stuff, but theydon’t know how to do it… The competent doctor not justknows, but actually knows how to work with people to effect-ively help them with dealing with their health prob-lems” [A07].

Information was also valuable about the different educa-tional approaches to be used. Doctors who had been

taught didactically via lectures needed guidance in how tolearn through reflecting on practice “there’s some intercul-tural differences in this so we as Western people are… wereally believe in reflecting on our own experiences and shar-ing them and there’s sometimes some problems with peoplewith other backgrounds—non-Western backgrounds—thatthey work from like a ‘we’ society and they’re not so keenon reflecting on their own experience, they don’t find thoseso important; so there’s some mismatch betweenour… perspectives on this” [N1].

Assessment at entry to trainingAssessment of doctors was advocated to enable training tobuild on current strengths and identify gaps and areas thatneeded extra input. One Australian program established anintensive assessment at the start of training using multiplechoice questions, written exams, and plans to introduce aclinical exam. The results are provided to GP supervisorswho can then target training appropriately. “Multiple choice,we as educators, about 15 of us, we sit there and we marktheir writtens, and then as they pop out of the multiplechoice, one by one, we grab them and we give them feed-back right there and then on what they’ve done. And thenwe collate that and we put it on a database and so thatinformation there, strengths and weaknesses summary really,is given to the supervisor before they enter practice, and aconsultation skills assessment so it takes a day and ahalf” [A11].

Direct observationFollowing an initial assessment, participants advocated fordirect observation of IMGs in practice. In Canada, this isencouraged for all doctors new to general practice as partof the competency-based education program. Again, thisstyle of education required explanation and reassurancethat it was being done to highlight how best to help doc-tors learn, rather than to remove them from the program.“Well we encourage all the preceptors to observe all of themvery closely at the beginning. We try not to target IMG’s,because that would be kind of unfair. But we like to knowearly when there’s gaps. And there’s a tendency for many ofthem to try and hide these gaps, out of fear of shame or get-ting kicked out. We have no intention of kicking them out,but we …we can send them to a newborn nursery and getthem doing physical exams and after 20 or 30, they’re prettygood… it’s better than a disaster where something importantis missed and they’re kind of pretending they know. Some ofthem are not watched on those sorts of exams” [C1].

Observation in practice was supplemented with observa-tion of learners during workshops and other educa-tional events.

Monitoring and early interventionProgram directors realized the benefit of monitoring IMGs’progress through their training. In the Netherlands, therewere monthly meetings to discuss information from mul-tiple sources. “Every month we discuss the residents who arehaving problems … for exams, for assessments, evaluationsand there’s many people from other cultural backgroundsthat are discussed far more than the percent Dutch that we

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have” [N1]. The same process is used in some Australiantraining organizations, in Canada, and in England with theaim of preventing the situation of IMGs repeatedly failingthe exam. Identifying doctors who are struggling by examfailure, seemed too late. “You intervene at a more appropri-ate stage, try and support them to overcome those deficits,hopefully they’ll come back into the program and flourishand move through. If you are leaving it very late in a processand not identifying it early enough, then that becomes aproblem and hence that is why we’ve got to start to look atthose sort of benchmarks along the way” [A09].

Flexible trainingGP trainees in Australia, New Zealand, UK, and Ireland arerequired to work for set blocks of time in general practiceand relevant hospital specialties. This approach presumesthat all trainees require equal time to achieve the sameeducational objectives but was thought to create inefficien-cies. “Why are we having to spend more resources onthem… and not being able to accelerate people through theprocesses… [we need to] translate some of those resourcesto those that are in greater need” [A06]. In contrast,Canada’s competency-based approach aims to match edu-cational input to specific needs and avoid unnecessaryrepetition if competency has already been reached. “So, weget IMG’s who’ve been obstetricians for 20 years in Egypt. Wewould adjust their program once we assess their competence,so they would spend relatively little time in obstetrics—justenough to maintain their skills and focus on the paeds thatthey may have never done” [C1].

Language skills and communication skillsExcellent language and communications skills were viewedas essential, and some respondents felt the current stand-ards set by regulators were too low for effective medicalpractice. One organization was working with a languageexpert. “We’ve brought in an English as Second Languageteacher, and she’s just developing exactly what she cando… many of them aren’t skilled at doing clinical language.They’re good at language, but in the context of aconsultation…Well I don’t know how they quite get into thesystem in Australia or even into our programs sometimes, butpeople who genuinely have significant deficits in the area ofculture, language, understanding, expression that are majorbarriers to good practice no matter how good your know-ledge is. And so we’re working at that; we put a lot of effortinto the people who fail the exams” [A16].

Modular learningGP trainees attendance at educational events and personalstudy provided an opportunity for tailoring education tolearner’s needs, but that flexibility could come at increasedcost compared to running a standardized program. “Withorganizations like xx and yy, we don’t want to buy the wholepack. We just want to be able to access, on an individualidentified learner’s needs, a module” [A06].

Developing a new professional identityHelping IMGs develop identities as GPs in their adoptedcountry was arguably the biggest challenge for educators.

They relied on setting up situations in which IMGs couldlearn by observation and discussion with peers and educa-tors in person, rather than didactic sessions. “I think thatthe face-to-face stuff is important for lots of reasons. I thinkthat as human beings we like that contact so I think it’sreally important that that’s there and that collegiality andthat discussion amongst the trainees themselves. They seehow other people behave or not just within the group, cer-tainly within the group but also outside of the group howthey behave or their understanding of what they should orshouldn’t be doing within practices and then the medicaleducation team” [A09]. This close interpersonal interactionwith feedback was seen as the best way of helping doctorslearn professionalism.

Supporting supervisorsMost GP trainees time and learning occurs while workingin supervised practice. This creates a vital role for GP super-visors and educators considered supporting them to per-form this role was similarly important.

Providing educational support across the whole curricu-lum was a significant challenge, exacerbated by IMGsrecruited to work in isolated areas with limited numbers ofGP supervisors. “There is a massive group out there thathave even greater needs and less fundamental skills or abil-ities—and that’s not necessarily their individual fault, it’s acollective issue—who are being put into general practiceenvironments in all geographic circumstances, and not sup-ported or trained to do so.” [A06].

Extra timeAnother key finding was that educators considered manyIMGs needed longer in GP training. “I’d say 30 percent ofour IMGs require two-and-a-half to three years of the samecontent.” [C1]. Similarly in UK, once IMGs were orientatedto the country they then progressed and gained the neces-sary skills. “My premise is that some of those people were ona trajectory, it was just too low a trajectory… I’ll slightlystereotype. Some join and they’re doing okay. They’re gainingknowledge throughout the three years but the trajectory isjust a little bit too slow and we hope that the extra exten-sions will enable them to pass. Some, they join but they’veactually never worked in the NHS or in the UK and in effectat least a year is a sort of cultural induction in the UK andthe NHS. And then, so they go along flat lining for a yearand then they have a trajectory that is the same trajectory asothers had from ST1 however it’s too late for them to crossthe line within the three years” [E2]. Expecting IMGs to com-plete in the same time frame as domestic graduates seemsunrealistic.

Targeted training programThe UK is planning a targeted training program for thosewho had been removed from the training program.Doctors will be invited to apply if they have “passed theworkplace based assessment and one of the two exam parts.The reason being that all our feedback is that people thatfail all three parts, or even two of the three, there’s no hope”[E2]. This initiative recognizes that additional training andtime may assist some who were unable to complete within

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the standard time-frame and program, to gain GPqualifications.

Clearer exit pointsEducators were reluctant to remove doctors from trainingprograms, preferring to offer remediation and hope forimprovement over time. There was a realization that thisapproach was done to be fair to IMGs. However, some hadbegun to take a different approach to fairness in establish-ing clearer exit points. “We’re not good enough yet atremoving people, early enough for the sake of themselves,their practices and their patients but we’re definitely gettingbetter at it” [A17].

Discussion

Our research has documented the experience of leaders inGP training in teaching IMGs, in Australia and five compar-able countries. Educators have a clear purpose to trainhigh quality GPs. They are aware that IMGs’ pre-trainingexperiences can include differences in language, under-graduate training, hospital practice, and how their countryof training defined professionalism and expected generalpractitioners to work. These differences resulted in learningneeds that educators could find hard to define. Few ofthese issues were explicitly discussed with IMGs who mayneed educational input across the breadth and depth ofthe GP curriculum. The Canadian competency-basedapproach enables educators to modify some aspects of theprogram to IMGs’ needs, but in other countries IMGs areexpected to train to become GPs in the same way and inthe same time as domestic graduates.

Educators try to build on IMGs strengths and to helpthem learn, while at the same time trying to avoid singlingout IMGs for fear this is viewed as racism. Educatorsdescribed initiatives to help IMGs but mostly these occurdiscretely rather than as a comprehensive package forIMGs across the whole training program. The overarchingneed was for educators to have authority to adapt trainingprograms to individual’s needs and to allow IMGs moretraining time. The initial part of training is often an orienta-tion to a country, its health system, medical culture andthe role of general practitioners. An orientation phase islikely to be most effective in supportive practices withexperienced, well-resourced and funded supervisors, ratherthan in under-resourced areas as currently occurs in somecountries. Investing in an extra orientation year mightreduce the number of doctors who fail exams before theend of their allotted training time, and who feel so over-whelmed that they leave under-served areas as soon asthey can.

Teaching professionalism is challenging; medical practiceis culturally bound and ethical practice is often determinedby different contexts. Educators advocated for opportuni-ties for role modeling, direct observation and workshops asnecessary for interpersonal learning. Expecting IMGs tolearn professionalism via books or online was consideredunrealistic.

Comparison with published literature

The need for extra training time is supported by the litera-ture. The American Board of Family Medicine comparedthe pass rates in their exam of Canadian and US graduatestraining in Canada and USA, and IMGs training in Canadaand USA. IMGs who trained as GPs in Canada, usually2 years training, performed less well in the American examthan USA or Canadian graduates (Falcone and Middleton2013). IMGs trained as GPs in the US, performed as well asAmerican trained graduates after 3 years training (O’Neillet al. 2016). Participants rated an alternative option, of clin-ical attachments in general practice prior to training, asvaluable in understanding the health system and the roleof GPs (Horman and Wright 2012; Warwick 2014).

Our finding that educators should have flexibility in howthey train and support IMGs, was also the conclusion fromstudies conducted to assess the differential attainment ofIMGs in UK general practice exams (Esmail and Roberts2013). One study articulated that “Doctors who are notequivalent at entry to GP specialty training are likely to strug-gle with the MRCGP unless they receive training thataddresses their specific needs” (Rendel et al. 2015).

Several authors concur with the view that IMGs benefitfrom language skills beyond the minimum requirements,especially as English language proficiency correlates withexam success (Grierson et al. 2017; Davda et al. 2018;Patterson et al. 2018). The need to teach culturally appro-priate, interpersonal competence was considered vitalrather than focusing on increased clinical knowledge(Patterson et al. 2018). This ties in with reports that IMGswho were successful in their exams at the first attemptstook proactive approaches, refined consultation skills, learntwith UK graduates, valued feedback and supportive rela-tionships (Ragg et al. 2015).

Strengths and weaknesses of the study

A strength of this article is that we consulted with highlyexperienced educators and merged the perspectives ofthose across Australia with those from comparable inter-national countries. We have opened the discussion to shareexpertise in an area that creates tension but can beavoided for fear of appearing prejudiced. A limitation isthat our perspective is from educators on formal trainingprograms. Different views about the tensions and solutionsmay have been expressed by IMGs, patients, practitioners,or independent educators or organizations.

Implications

Training systems that assume all learners need the sameinput creates inefficiencies. Instead our participants arguethat different inputs are needed to reach the same output.The benefit of more flexible training could create a moreefficient system whereby those who learn quickly can pro-gress quickly and others can take more time. Indeed, this isour impression of the benefits of the competency-basedapproach to training used in Canada. This change couldbenefit domestic graduates as well as IMGs.

A shift in thinking and practice is needed from notionof equity and fairness meaning a standard training

1070 S. M. WEARNE ET AL.

program. Instead equity could focus on educational needand educational outcomes. This is an argument for learner-orientated training. Rather than presuming all trainees arethe same, educators need to judge how best to help indi-vidual doctors to become GPs. While countries rely onIMGs to work in difficult areas to staff, it is appropriate tosupport and train them. If adopted, this approach will needcareful evaluation.

Conclusions

IMGs bring different skills and may need longer and moreflexible training. Standardized programs are unlikely to besuccessful and individual approaches are needed, particu-larly at the beginning of training, to prevent unnecessaryrepetition or educational gaps.

Acknowledgements

S.W. asserts that the views expressed here are her own and not neces-sarily those of her employer the Commonwealth Departmentof Health.

Disclosure statement

The authors report no conflicts of interest. The authors alone areresponsible for the content and writing of this article.

Glossary

International Medical Graduates: Are medically qualified doc-tors, who live, work and/or train in a different country to thecountry where they obtained their primary medical degree.International medical graduates are synonymous with foreignmedical graduates and overseas trained doctors.

Notes on Contributors

Susan Wearne, BM, PhD, MMedSc, FRACGP, FACCRM, DCH, DRCOG,DFFP, GCTEd, is a Clinical Associate Professor in the Academic Unit ofGeneral Practice, at the Australian National University, a GP inCanberra and Senior Medical Advisor in the Health Workforce Divisionof the Commonwealth Department of Health.

James Brown, MBBS, FRACGP, FACRRM, MFM(clin), is a GP supervisorand the Director of Education Quality improvement with EasternVictoria GP training. He is also a senior lecturer and PhD candidatewith Monash University.

Catherine Kirby, BSocSci(hons), PhD, is the Research Manager forEastern Victoria GP Training and Adjunct Senior Lecturer Monash RuralHealth, Churchill, Victoria.

Professor Dave Snadden, MBChB, MCISc, MD, FRCGP, CCFP, is theRural Doctors' UBC Chair in Rural Health, Department of FamilyPractice, University of British Columbia Faculty of Medicine, NorthernMedical Program, Prince George, BC, Canada.

ORCID

Susan M. Wearne http://orcid.org/0000-0002-8079-9304James B. Brown http://orcid.org/0000-0002-7262-1629Catherine Kirby http://orcid.org/0000-0003-3398-6841

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