The IMG Supervisor’s Toolbox

The GPSA IMG toolbox is a repository of useful references and resources to help GP supervisors support their IMG registrars.

The Supervising the IMG guide is the definitive resource on supervising IMGs. See also the webinar on this topic and our Supporting the International Medical Graduate (IMG) web page.

For consultation skill teaching, please also refer to the Consultation Skills Toolbox and the Consultation Skills Teaching plans here.

There are a number of broad principles that should guide the supervision of IMG GP registrars.

While these are appropriate to all registrars, they have particular importance for IMGs.

Avoid generalisations and stereotyping

International Medical Graduates are not a homogenous group, and have a wide range of knowledge, skills, attitudes, experience, and backgrounds, even within the same cultural group. This may sound obvious, but it is critical to avoid generalisations or stereotyping, and for supervisors to regard every IMG as unique. Where issues arise, it is critical to specifically ‘diagnose’ the problem (educational, personal etc.), rather than generalising it as being ‘cultural’ or ‘language’.

Identify differences, not deficits

While often associated with posing educational and training challenges, IMG GPRs can bring a wealth of positive skills, attributes and expertise to GP training and the general practices in which they train. Such positives include:

A broader world view
Experience of alternative health systems (often in disadvantaged communities)
Specific clinical skills
Second (or third) languages
Resilience to setbacks

Reflecting this, a recent paper on supporting IMG GPRs argued that the focus on supervision of IMG GPRs should be on ‘difference’, not ‘deficit’. Furthermore, the authors stated that labelling IMGs as having learning needs was unfair without also acknowledging their unique strengths.

Expect the need for broad supports

The IMG GPR is may need increased support across all facets of training – educational, pastoral, personal and professional.

While the transition from the hospital to the general practice setting is potentially highly challenging for all registrars – characterised by a breath of clinical problems, relative independence of decision making, time pressures, management of uncertainty, new practice systems, financial and billing issues – this challenge is likely to be exacerbated for many IMGs.

It is essential that the supervisor of IMG GPRs is willing to take on this broad responsibility, and to be overt about their support role in all aspects of the registrar’s development.

Foster a culture of learning and feedback

It is vital to foster an open and honest culture of teaching, learning and feedback in the practice.

Supervisors should use a broad range of teaching methods and focus on skill development, rather than clinical knowledge. It may be necessary at times for the supervisor to have challenging conversations with the IMG GPR on sensitive areas like cultural norms and communication issues. Thus, it is critical for both supervisor and registrar to agree on a process for frank feedback, while also maintaining a culture of mutual support.

Provide comprehensive orientation

One of the key planks in effective supervision of the IMG GP registrar is provision of a comprehensive orientation at the commencement of the training term.

In addition to the usual clinical and administrative benefits, there is evidence that effective orientation of IMGs can increase their sense of professional identity, morale and belonging. IMG registrars are likely to benefit from discussion of Aboriginal and Torres Strait Islander culture, as well as Australian culture more broadly, and community support. This may also include an orientation to the IMG registrar’s partner and family.

Engage assistance early

Supervisors need to engage appropriate support from their regional training organisation, or elsewhere, when performance issues arise.

Performance issues for IMG GPRs are often complex and may require specialist input. Supervisors should therefore have a low threshold for seeking guidance from the registrar’s medical educator.

Cultural

There are multiple issues related to cultural differences that are challenges for IMGs. The culture of medicine varies enormously from one country to another. The Australian medical system is likely to be vastly different to that in which the IMG trained, in structure, funding, and complexity. It is important that the supervisor help them to build confidence in working within a new system without feeling overwhelmed.

IMG registrars have described the challenges of understanding Australian culture as a significant training issue, including aspects as diverse as dress codes, sexual practices, and alcohol consumption. It has been found that IMGs may at times impose their own cultural norms during a consultation. Conversely, racism and community acceptance have been identified as issues for IMGs.

IMGs may also need to develop cultural competence in managing patients from multiple cultural groups, reflecting the diverse multicultural nature of Australia.

- Ask your registrar about their previous medical practice.
  - How did they interact with patients?
  - Did they work as part of a team?
  - How did they interact with specialists and other care providers?
  - What was the ‘medical culture’ in their home country?
- Ask your registrar whether any aspects of the Australian culture are particularly challenging for them in their interaction with patients.
- Ask your registrar whether they have ever been subjected to racism and how they dealt with it.
- Ask your registrar to reflect on their own ‘cultural lens’ i.e., their own unique personal worldview influenced by the cultures that nurtured them.
  - How might that impact on the approach to patients from other cultures?

Resources

Navigating Medicare

Managing Medicare Billing

Medicare Compliance

Professional and Ethical Practice

Communication Skills Toolbox

VIDEO: How do cultural values and perceptions impact on clinical care?

Communication

It is well known that some IMG registrars have significant language issues that may impact on satisfactory communication, both with patients and peers. This has clear consequences for clinical outcomes, examination performance and confidence.

Most IMGs will have English as their second (or third or fourth!) language, even though they may have been exposed to English as the language of instruction. IMG GPRs may struggle with fluency and structure, and comprehension of colloquial English. IMGs have also specifically identified that understanding Australian slang, idioms and mannerisms can be a challenge.

Specific scenarios that require the use of specific communication skills can also be challenging, for example communicating with children, managing the angry patient, saying no, breaking bad news, motivational interviewing, palliative care, and grief counselling.

Areas in which IMGs may have problems are:

Picking up patient cues (verbal and non-verbal)
Demonstrating empathy
Establishing rapport
Appropriately responding to difficult situations
Translating medical jargon into lay language
Clarity of written communications

- - Ask your registrar what communication skills training they have done in the past, if any.
  - Employ a broad range of teaching methods to focus on communication skill development e.g. direct observation, role play, random case analysis.
  - Give explicit feedback on communication skill issues, including written English, even though it might be challenging.
  - Demonstrate your ‘spiel’ for explanation and management.
  - Encourage your registrar to use simple communication strategies in the consultation (see diagram 1).
  - Discuss non-verbal cues and their likely meanings in Australian general practice.
  - Discuss and role play situations where specific communication strategies may be required (as above).
  - Encourage reflective practice in your registrar i.e. ‘How well did I communicate in that consultation?
  - Encourage your registrar to watch local TV shows, read newspapers, see Australian films, attend local venues e.g. sports clubs or RSL (if comfortable) etc. to help refine their everyday English language skills.
  - Consider online learning courses e.g. Doctors Speak Up website13 or assistance from professional linguists/language teachers.
  - Provide useful phrases

Resources

History taking skills

Writing quality referrals

VIDEO: Australian slang

Australian slang dictionary

Slang terms in the consulting room

Website: Doctors Speak Up

VIDEO: Doctors Speak Up website

Clinical

The pass rate for Fellowship examinations is lower for IMGs, including in those assessments of applied clinical knowledge. Even where knowledge may be reasonable, it has been observed that the application of clinical knowledge can be an issue for some IMGs. Below are some of the key areas in which IMG registrars may have clinical challenges:

History Taking – History taking can be compromised by language barriers, communication issues and cultural differences, such as a biomedical approach to asking questions of patients rather than a dialogue. It may also be culturally unacceptable to take sexual history of patients of opposite genderor exploring social circumstances like intimate partner violence.
Physical Examination – In some cultures, physical examination is less commonly performed, or it may not be appropriate for a male doctor to examine a female (or vice versa). As well, more intimate examinations like a pelvic examination may be deemed culturally unacceptable.
Management Planning – This is another potential lacking area of clinical skill development for IMG GPRs. The role of the allied health practitioner might be unfamiliar to many IMGs, reflecting the medical culture and access to resources in which they trained.
Investigations – The rational use of investigations may be challenging for IMGs dues to challenges in effective history taking and examination, lack of a patient-centred approach, intolerance of uncertainty, and the influence of past training or clinical practice.
Prescribing – Prescribing is another recognised area of clinical skill development for IMG GPRs, with similar factors underpinning it.

- - Ask your registrar about the nature of their past clinical experience i.e. range of demographics, presentations etc.
  - Help your registrar identify their learning needs and clinical knowledge gaps using appropriate methods e.g. clinical self-assessment tool, random case analysis.
  - Discuss local and national disease epidemiology.
  - Encourage use of appropriate clinical resources and guidelines e.g. RACGP Red Book, Therapeutic Guidelines, Health Pathways.
  - Focus teaching on rational use of tests and treatments.
  - Use the GPSA teaching plans for in-practice teaching on identified knowledge deficits.

Resources

History taking skills

Physical examination skills

Chronic disease management care planning

Rational test ordering

Rational prescribing guide

Consultation

Registrars often struggle to facilitate an effective, organised, and time-efficient consultation with their patients. This is particularly the case for many IMG registrars, where the primacy of the general practice consultation may not have been a feature of their past training or experience.

Areas such as building the doctor-patient relationship, opening the discussion, understanding the patients perspective, sharing information, reaching agreement and providing closure may be challenging for many IMG registrars.

Resources

Health Education, brief intervention and motivational interviewing

Patient centred care

Follow up and safety netting

Professional and medicolegal

Professional and ethical practice

Professionalism is another area which has been identified as a focus for skill development for IMGs. This includes issues such as setting boundaries, difficulties obtaining consent, reluctance to disclose errors, and interpersonal communication.

Medicolegal

There is evidence that IMGs from some countries have a higher risk of malpractice claims and adverse findings than Australian trained doctors.29 Common themes of ‘at risk’ countries of training include English as a second language, and different medical education and health systems to Australia. Specific areas include opiate prescribing and managing drug seekers (including being able to ‘say no’). For example, some drug seeking patients see IMGs as a ‘soft target’ and will sometimes be aggressive to get their way. Many IMGs may struggle with how to decline prescription requests.

Resources

Teaching professionalism guide

Teaching professionalism FAQ

Professional and ethical practice teaching plan

Identifying and Managing Medico-legal Risks

Teaching and Learning

IMG registrars are known to have lower pass rates in Australian GP training. One of the many potential factors underpinning this relates to the approach to learning. Below are some of the key areas of teaching and learnnig that may be challenging for IMGs.

Cultural approaches to learning – Many cultures embrace a strong hierarchy in the educational process, in which the teacher is seen as an expert, rather than a facilitator of knowledge. In such settings, there is often much less emphasis on identification of the learners individual learning needs and self-directed learning. The IMG registrar may be less comfortable speaking up or challenging their teacher.
Exam Preparation – IMGs are known to have lower pass rates in postgraduate examinations than local doctors, likely due to cultural issues, communication and English language skills, clinical skills and study techniques.
Oral examinations – In many settings oral examinations are traditionally examiner led, rather than candidate-led, and IMGs may need to change their approach from passivity and be encouraged to speak confidently about what they know.
Feedback – Factors such as perceived power dynamics between teacher and learner, communication issues, attitudes towards critique, and potential vulnerability in evaluation may differ for IMGs. In many cultures, critique is not a usual part of day-today practice and can therefore be misconstrued as evidence of a serious failure, associated with loss of face, shame and embarrassment.
Help seeking – It is known that the approach to help seeking varies between cultures and can impact on learning. IMG registrars may not ask for assistance directly, but may instead more subtly ‘hint’ at problems. This may be overlooked or misinterpreted by the supervisor.

Resources

Planning learning FAQ

Supporting GP registrars with the AKT and KFP

Preparing GP registrars for StAMPS

Feedback guide

Feedback FAQ

A “Call for Help” List for Supervisors and Registrars

VIDEO: Socratic versus Confucian conceptions of teaching and learning

Video: Stages of competence

Personal

For many IMGs, personal stressors are magnified. Migration and displacement may mean the absence of family and community supports. IMGs have described relocation to rural areas as a particularly stressful time, commonly associated with separation from partners and isolation. Family concerns are thus common. IMGs may be subject to prejudice or racism, which understandably can have a major impact on wellbeing. As well, IMG GPRs may have to adapt to a sudden change in status (specialist to trainees).

- - Get to know the story behind your registrar – their background and life.
  - Let the registrar know that you ‘have their back’ at all times.
  - Encourage participation in community events.
  - Encourage your registrar to have their own GP.

The IMG Supervisor’s Toolbox

The GPSA IMG toolbox is a repository of useful references and resources to help GP supervisors support their IMG registrars.

The Supervising the IMG guide is the definitive resource on supervising IMGs. See also the webinar on this topic and our Supporting the International Medical Graduate (IMG) web page.

For consultation skill teaching, please also refer to the Consultation Skills Toolbox and the Consultation Skills Teaching plans here.

Principles ofIMG Supervision

Topics

There are a number of broad principles that should guide the supervision of IMG GP registrars.

While these are appropriate to all registrars, they have particular importance for IMGs.

Avoid generalisations and stereotyping

Identify differences, not deficits

While often associated with posing educational and training challenges, IMG GPRs can bring a wealth of positive skills, attributes and expertise to GP training and the general practices in which they train. Such positives include:

Reflecting this, a recent paper on supporting IMG GPRs argued that the focus on supervision of IMG GPRs should be on ‘difference’, not ‘deficit’. Furthermore, the authors stated that labelling IMGs as having learning needs was unfair without also acknowledging their unique strengths.

Expect the need for broad supports

The IMG GPR is may need increased support across all facets of training – educational, pastoral, personal and professional.

It is essential that the supervisor of IMG GPRs is willing to take on this broad responsibility, and to be overt about their support role in all aspects of the registrar’s development.

Foster a culture of learning and feedback

It is vital to foster an open and honest culture of teaching, learning and feedback in the practice.

Provide comprehensive orientation

One of the key planks in effective supervision of the IMG GP registrar is provision of a comprehensive orientation at the commencement of the training term.

Engage assistance early

Supervisors need to engage appropriate support from their regional training organisation, or elsewhere, when performance issues arise.

Performance issues for IMG GPRs are often complex and may require specialist input. Supervisors should therefore have a low threshold for seeking guidance from the registrar’s medical educator.

Cultural

IMGs may also need to develop cultural competence in managing patients from multiple cultural groups, reflecting the diverse multicultural nature of Australia.

Resources

Communication

It is well known that some IMG registrars have significant language issues that may impact on satisfactory communication, both with patients and peers. This has clear consequences for clinical outcomes, examination performance and confidence.

Specific scenarios that require the use of specific communication skills can also be challenging, for example communicating with children, managing the angry patient, saying no, breaking bad news, motivational interviewing, palliative care, and grief counselling.

Areas in which IMGs may have problems are:

Picking up patient cues (verbal and non-verbal)

Demonstrating empathy

Establishing rapport

Appropriately responding to difficult situations

Translating medical jargon into lay language

Clarity of written communications

Resources

Clinical

Physical Examination – In some cultures, physical examination is less commonly performed, or it may not be appropriate for a male doctor to examine a female (or vice versa). As well, more intimate examinations like a pelvic examination may be deemed culturally unacceptable.

Management Planning – This is another potential lacking area of clinical skill development for IMG GPRs. The role of the allied health practitioner might be unfamiliar to many IMGs, reflecting the medical culture and access to resources in which they trained.

Investigations – The rational use of investigations may be challenging for IMGs dues to challenges in effective history taking and examination, lack of a patient-centred approach, intolerance of uncertainty, and the influence of past training or clinical practice.

Prescribing – Prescribing is another recognised area of clinical skill development for IMG GPRs, with similar factors underpinning it.

Resources

Consultation

Registrars often struggle to facilitate an effective, organised, and time-efficient consultation with their patients. This is particularly the case for many IMG registrars, where the primacy of the general practice consultation may not have been a feature of their past training or experience.

Areas such as building the doctor-patient relationship, opening the discussion, understanding the patients perspective, sharing information, reaching agreement and providing closure may be challenging for many IMG registrars.

Resources

Professional and medicolegal

Professional and ethical practice

Professionalism is another area which has been identified as a focus for skill development for IMGs. This includes issues such as setting boundaries, difficulties obtaining consent, reluctance to disclose errors, and interpersonal communication.

Medicolegal

Resources

Teaching and Learning

IMG registrars are known to have lower pass rates in Australian GP training. One of the many potential factors underpinning this relates to the approach to learning. Below are some of the key areas of teaching and learnnig that may be challenging for IMGs.

Exam Preparation – IMGs are known to have lower pass rates in postgraduate examinations than local doctors, likely due to cultural issues, communication and English language skills, clinical skills and study techniques.

Oral examinations – In many settings oral examinations are traditionally examiner led, rather than candidate-led, and IMGs may need to change their approach from passivity and be encouraged to speak confidently about what they know.

Help seeking – It is known that the approach to help seeking varies between cultures and can impact on learning. IMG registrars may not ask for assistance directly, but may instead more subtly ‘hint’ at problems. This may be overlooked or misinterpreted by the supervisor.

Resources

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