For clarity, the common issues for IMG GPRs are categorised in the accordion sections below. These headings reflect the findings of research work in the area and observations in practice. There is considerable overlap across these categories, for example communication and consultation skills, but hopefully such a categorisation provides a practical list for supervisors to help ‘diagnose’ and manage issues in their IMG GPRs.
Issues are most likely to emerge and be identified in the day-to-day interactions of the supervisor and registrar. However, it can also be worthwhile attempting to identify any potential issues early in the placement using a range of tools. These include the ‘IMG registrar self-assessment tool’ and ‘Supervisor assessment tool for IMG registrar’.
A culture is a set of beliefs and customs, rules of behaviour, and collective ideas that belong to a particular group or society. There are multiple definitions of culture, but in essence it is a collective understanding and way of living.
There are multiple issues related to cultural differences that are challenges for IMGs. Those specifically related to communication, the doctor-patient consultation, clinical skills, professionalism and teaching and learning are discussed in separate sections of this guide.
The culture of medicine varies enormously from one country to another. Medical culture does not refer only to the practices and processes of the health care system, but also the relationships and behaviours of the people within them. IMGs have previously identified that adapting to the Australian medical culture is a specific challenge and learning need.6
The Australian medical system is likely to be vastly different to that in which the IMG trained, in structure, funding and complexity. Adapting to the scope and boundaries of a new system can be bewildering for an IMG. It is important that the supervisor help them to build confidence in working within a new system without feeling overwhelmed.
The medical culture in Australia is also likely to be different. In many countries, the doctor operates from a position of considerable power compared to that of the patient. This is in stark contrast to the relatively equitable doctor-patient relationship common in Australian health care. For example, in many overseas medical cultures, the patient would rarely or never question their doctor. Transition to this non-hierarchical model and adjustment to a change in status can be a
significant challenge for some IMG GPRs.
Additionally, many IMGs may need to adjust from being a respected specialist practitioner in their own country to being a trainee again. The need to study and pass exams in the new discipline of general practice can take a toll on self-esteem and confidence. It has been described that one of the important factors in IMGs adjusting to a new medical system is to maintain a positive self-image as a professional.
Another contrasting feature of Australian general practice with many overseas health care systems is the focus on continuity of care. Continuity of care is considered a core feature of both primary care and high-performing healthcare systems, and is associated with improved patient satisfaction, decreased emergency department attendance, decreased hospitalisation, and decreased patient mortality.7 While it is regarded as integral to Australian general practice, it is often non-existent in many other settings.
Australia is a multicultural society, with almost half of Australians either born overseas or had one or both parents who were born overseas. In addition to adjusting to the cultural norms of mainstream Australia, IMG GPRs also need to develop cultural competence in managing patients from multiple cultural groups. Additionally, IMG GPRs need specific cultural competency skills in managing Aboriginal and Torres Strait Islander people, where cultural competency has been described as key strategy for reducing inequalities in health care access and improving the quality of care for this population.8
For the purposes of this guide, clinical aspects include the knowledge and skills required for effective diagnosis and management – history taking, physical examination, generation and prioritisation of a differential diagnosis, rational use of investigations, rational prescribing, formulating a management plan and procedural/ emergency skills. Clinical knowledge and skills, and their application to practice, are another well recognised area of difference for IMGs compared to Australian registrars.
As previously stated, the pass rate for Fellowship examinations is lower for IMGs, including in those assessments of applied clinical knowledge. There are likely to be many factors underpinning this, including cultural; English language comprehension; study techniques; and previous medical training. Knowledge gaps can be particularly prominent where the IMG has previously trained and worked as a specialist in their home country, and/or where they have worked in a narrow field of practice prior to starting GP training. Even where knowledge may be reasonable, it has been observed that the application of clinical knowledge can be an issue for some IMGs.
The epidemiology of many diseases is very different in Australia compared to other countries. Furthermore, GP supervisors have previously identified that IMGs may be unfamiliar with some common Australian general practice presentations, such as childhood asthma and psychosocial problems. This may have a cultural dimension – for example, in some countries, depression may not even be considered an illness.
Additionally, patients in Australia may present much earlier in the course of their illness compared to patients in other settings, leading to a higher proportion of undifferentiated presentations.
In many countries, the focus of clinical practice is on assessment and management of acute problems, and preventive care is a luxury only available to a small proportion of the population. Hence, understanding of screening and preventive health practice is a recognised knowledge gap for many IMGs.
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.
Ask your registrar whether there are any specific areas of history taking they are uncomfortable with e.g. sexual history taking etc. and focus on these areas during teaching.
Encourage the use of simple communication strategies for effective history taking – see Diagram 1.
Encourage the use of effective strategies for identifying the patient’s agenda – see section on patient-centred care.
Use the GPSA teaching plan on history taking.
Practice psychosocial history taking.
There are a number of recognised differences in the approach of IMGs to physical examination. There is a widely held cultural expectation in Australian health care that patients should be examined when they visit the doctor. However, in some cultures, physical examination is less commonly performed, or it may not be appropriate for a male to examine a female (or vice versa). As well, more intimate examinations like a pelvic examination may be deemed culturally unacceptable.
Ask your registrar whether there are any specific areas of physical examination they are uncomfortable with e.g. pelvic examination etc.
Encourage your registrar to consider a focused examination as a fundamental element of the consultation unless there is justification to omit it – this may be as simple as BP check.
Discuss the role of the chaperone in general practice.
Use the GPSA teaching plan on physical examination.
Another core clinical skill is formulation of a management plan, ideally one that genuinely includes the patient’s input (see section on patient-centred care and shared decision making on pages 16-18). This is another potential 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.
Another clinical skill which may be particularly challenging for IMG GPRs is the rational use of investigations. A number of factors may underpin this, including 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.
Ask your registrar whether there are any specific areas of physical examination they are uncomfortable with e.g. pelvic examination etc.
Encourage your registrar to consider a focused examination as a fundamental element of the consultation unless there is justification to omit it – this may be as simple as BP check.
Discuss the role of the chaperone in general practice.
Use the GPSA teaching plan on physical examination.
Prescribing is another recognised area of clinical skill development for IMG GPRs, with similar factors underpinning it.
Ask your registrar whether there are any specific areas of physical examination they are uncomfortable with e.g. pelvic examination etc.
Encourage your registrar to consider a focused examination as a fundamental element of the consultation unless there is justification to omit it – this may be as simple as BP check.
Discuss the role of the chaperone in general practice.
Use the GPSA teaching plan on physical examination.
At the heart of general practice is the consultation, and it is the consultation that provides the context for the entirety of general practice education. The consultation can be viewed most simply as the sharing of information between patient and doctor, in order to develop both a common understanding and a plan of management.
Consultation skills can be considered as the range of skills that underpin the effective doctor-patient encounter. They include core clinical skills and communication skills (as discussed in previous sections), but also a range of skills unique to the general practice encounter, like shared decision making.14
While a structured consultation is second nature for an experienced GP, 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.
Over the years, there have been several formal models of the consultation described in the international literature. One of the most enduring is Neighbour’s ‘The Inner Consultation’15, in which he proposed that the general practice consultation was ‘a journey, not a destination’, and described five ‘checkpoints’ along the way.
• Connecting – Have we got rapport?
• Summarising – Do I know why the patient that has come today?
• Handing over – Have we agreed on a management plan?
• Safety netting – Have I covered the ‘what ifs’?
• Housekeeping – Am I in good shape for the next patient?
Closer to home, Murtagh stated that the objectives of the general practice consultation are to:
A. Determine the exact reason for the presentation.
B. Achieve a good therapeutic outcome.
C. Develop a strong doctor-patient relationship.16
Invite your registrar to sit in and observe your consultations, and then afterwards specifically discuss consultation structure.
Use various consultation models as frameworks to teach IMG GPRs about the importance of a structured, patient-centred and safe consultation. Focus on specific areas which IMG registrars find challenging, like connecting with the patient and handing over.
Watch example consultations with your registrar and specifically discuss consultation structure.
Another useful framework for considering the range of consultation issues for IMGs is the Kalamazoo consensus statement, a widely adopted model for assessing communication skills.17 The Kalamazoo statement describes seven essential sets of consultation tasks, namely:
1. Building the doctor-patient relationship.
2. Opening the discussion.
3. Gathering information.
4. Understanding the patient’s perspective.
5. Sharing information.
6. Reaching agreement.
7. Providing closure.
These are elaborated below.
Establishing rapport with a patient is a critical step in best practice patient care. Rapport is positively established through a series of verbal and non-verbal communication strategies, as previously discussed. On the other hand, previous studies have shown that inappropriate use of the computer can negatively impact on rapport building.18
Establishing and building the doctor-patient relationship is not a focus of medical training and medical practice in many countries. But while the registrar’s background, confidence and personality will influence how well they can establish rapport, this skill can also be learnt.
Teach your registrar the micro-skills of how to build rapport, including appropriate social ‘chit-chat’, using the patient’s preferred name, and putting the patient at ease.
Discuss the negative impact of the computer on building rapport.
We haven’t met before.
Tell me a bit about yourself…
I’m really sorry to hear that.
That must be really tough.
Just excuse me while I use the computer to take some notes.
Opening the consultation is a critical skill that sets the tone for the rest of the encounter.
Allow the patient to talk uninterrupted.
How can I help you today?
What can I do for you today?
What would you like to talk about today?
This comprises history taking and examination skills and is covered in the section on clinical skills.
Use open ended questions.
Screen for other problems.
Clarify issues.
Actively listen.
Patient-centred care (PCC) is a model of care that is defined by understanding the whole person, respecting patient preferences and engaging patients fully in the process of care.19 In practical terms, it involves establishing rapport and a connection with the patient, identifying the patient agenda, and sharing decision making.
McWhinney, an academic GP from Canada, stated that patient-centred care is an approach where ‘the health care provider tries to enter the patient’s world to see illness through the patient’s eyes’.20 Patient-centred communication is positively associated with patient satisfaction, adherence and better health outcomes.21 It is rightly regarded as the foundation of good medical practice.
However, it has been found that many IMGs are unfamiliar with the model of PCC.22 Previous research has established that some IMGs rely more on a paternalistic rather than patient-centred consultation style. This may reflect an absence of PCC training in the curricula of many international medical schools, or the hierarchical model of patient care in many countries. In contrast to the PCC model, features of the consultation with IMGs have been found to include:
IMGs can therefore encounter problems when trying to reconcile the relatively unfamiliar PCC model with their own understanding of the consultation. In this regard, IMGs have been described as ‘expert novices’ – biomedical experts but novices in PCC.22
The potential consequences of this non-PCC approach are multiple, including negatively impacting on the doctor-patient relationship; failing to identify the patient’s agenda; failing to consider hidden agendas23; missing patient cues; sounding blunt, judgemental or unempathic; failing to involve patients in decision making; and failing to negotiate the doctor and patient agendas.
Supervisors play a critical role in facilitating a more PCC approach to consultations in the IMG registrars. This goes beyond simply educating registrars on the need to consider the patient more or include some appropriate phrasing – indeed, the latter may exacerbate the tendency to adopt formulaic and ultimately ineffective communicative strategies.
IMGs need the opportunity to receive feedback on patient encounters and reflect on practice to embed these skills.
Use a range of teaching methods e.g. direct observation, role play and feedback, to teach PCC.
Explicitly discuss the patient-centred care model and encourage your registrar to read about further about it.
Discuss the specific areas of framing, topic control and coherence.
Discuss hidden agendas, and patient groups where they may be more common – teenagers, middle-aged men and the elderly.
• Discuss the use of ICE – ideas, concerns, and expectations – to help elicit the patient agenda.
Murtagh lists as the first point in patient management ‘Tell the patient the diagnosis’.16 It is critical to formulate and deliver a simple and clear explanation, including the provisional and differential diagnosis and the evidence supporting this, before discussing management. As appropriate, this explanation should also specifically refer to the patient’s ideas, concerns and expectations. It is also essential to check the patients understanding. Sharing information in this way is a common skill gap for many registrars, and may be more prevalent in some IMGs.
Another essential skill for general practitioners is the management of uncertainty. There is conflicting evidence on whether IMGs have a different level of harm avoidance and tolerance of uncertainty to Australian trained doctors.24 But in many countries, patients are less accepting of uncertainty and as a result many IMGs have been trained to ‘make the diagnosis’ and may be uncomfortable managing undifferentiated presentations. Management of uncertainty is an important area for which supervisors can support their IMG GPRs using appropriate strategies.
Use mini-role play as a method to practice delivery of brief explanations.
Discuss approaches to discussing uncertainty with the patient – a useful resource is the GPSA guide to Managing Uncertainty
Emphasise the frequency of undifferentiated presentations in general practice and that making a diagnosis is not always required.
I have heard your story and examined you, and what I am thinking is…
I am not entirely sure what to make of this…
So, I think what I have heard is…
Development of a management plan is another key consultation skill. While this requires satisfactory clinical knowledge and skills, it also requires understanding and application of shared decision making. Shared decision making is an approach where patients are genuinely involved in decisions around their care.25 As above, it is a core feature of PCC.
Explicitly discuss the shared decision making approach and encourage your IMG registrar to read about further about it.
If you were to go home and tell your family what was the plan was, what would you tell them?
Where do you think we should go from here?
Closing the consultation is an important step but one that IMGs may struggle with. This includes plans for follow-up and effective safety netting.
Has this visit addressed your problems?
When should we next meet to follow this up?
Clinical reasoning encompasses skills in effective data gathering (history, examination and investigation), data synthesis and interpretation, communication, managing uncertainty, patient-centred care, and evidence-based medicine. It is a core element of high-quality general practice.
Many of the core skills of clinical reasoning, and the reasons that these might be problematic for IMGs, have already been discussed. Additionally, IMG registrars may never have been introduced to some of the core concepts of clinical reasoning – the diagnostic process, cognitive bias, models for differential diagnosis generation e.g. Murtagh’s model16; VITAMINSABCDEK.26
Clinical reasoning has been identified as a specific area of skill development for IMGs in its own right.2 While clinical reasoning skills develop with experience, reflection and exposure to multiple patient presentations, they can also be taught. GP supervisors can therefore play an explicit role in the development of clinical reasoning skills in their IMG registrar, in particular to ‘think like a GP’.
Medical professionalism is regarded as one of the core factors in providing high-quality patient care.27 Professionalism is closely associated with improvements in doctor-patient relationships, patient satisfaction, and healthcare outcomes.28 A good doctor is intrinsically a professional doctor.
However, professionalism, and more specifically medical professionalism, is culturally determined and varies widely across countries and contexts. Perhaps not surprisingly therefore, professionalism is another area which has been identified as a focus for skill development for IMGs.2 This includes issues such as setting boundaries, difficulties obtaining consent, reluctance to disclose errors, and interpersonal communication.
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.
The international literature on teaching skills in professionalism describes two complementary approaches. The first is teaching of the so-called ‘cognitive base’ of professionalism, that is the specific knowledge and skills in professional practice e.g. gaining consent, discussing confidentiality and dealing with error. The second approach is the teaching of professional attributes through role modelling and experiential learning.
Ensure your registrar has read the Medical Board of Australia Code of Conduct.
Explicitly encourage your registrar to disclose any mistakes or near misses and reassure them that they will be dealt with in a supportive and blame-free manner.
Discuss S8 prescribing as part of orientation.
Read the GPSA Guide Teaching Professionalism.
Use the GPSA Shades of Grey Flash Cards to discuss and/or role play challenging professional and ethical scenarios.
Successful completion of GP training requires high level skills not only in clinical general practice, but also effective learning. This includes effective knowledge and skill acquisition and application, efficient study practice, the ability to receive and act on feedback, and reflective practice.
As previously described, IMG registrars are known to have lower pass rates in Australian GP training.31 One of the many potential factors underpinning this relates to the approach to learning.
There are well recognised cultural differences in the nature of teaching and learning across different contexts. 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. Furthermore, the style of learning is often focussed on rote learning and fact memorisation, rather than applied or problem based.
As a result, the approach to teaching and learning in many international medical schools is very different to that in Australia. This may impact significantly on an IMG GPRs ability to learn in Australian general practice training.
Explore your registrar’s previous experiences
in education and training.
Over recent years there has been an increasingly strong focus on study skills and techniques in GP training, especially for those registrars unsuccessful in Fellowship examinations. It has been described that many IMGs use outdated study techniques such as rote learning, and utilise a limited range of resources, rather than more evidence-based approaches like spaced practice. Furthermore, many IMGs are older and may have difficulties with efficient studying and recall, as well as juggling work and family commitments.
Explore your registrar’s approach to study and the techniques they use.
Refer to best practice study techniques.
Explicitly discuss the need to develop skills and apply knowledge, rather than just learning factual information.
Encourage a range of learning resources e.g. video, podcasts etc.
Encourage the registrar to join a study group – the value of group discussion is very high.
Passing the Fellowship barrier examinations is the goal of every registrar in training and can be the source of significant anxiety and stress. Unfortunately, IMGs are known to have lower pass rates in postgraduate examinations than local doctors, including in Australian GP training.2 There are likely to be many factors underpinning lack of exam success – cultural issues, communication and English language skills, clinical skills, study techniques – which are described in the sections above.
One particular difference between Australia and many overseas countries is the approach to oral examinations. IMGs may be more familiar with an examination style of interrogation and identification of knowledge gaps, rather than facilitating the demonstration of what a candidate knows. 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.
While there is a wealth of literature on the reasons underpinning exam failure, it is also of value to reflect on the factors for exam success in this cohort.32 A paper from the UK described six main themes for success, including:
Supervisors can foster and encourage these broad approaches and attitudes in their IMG GPRs to maximise the chances of success in the exams.
Ask your registrar to complete the selfassessment
tool to help identify potential barriers to exam success.
Dedicate in-practice teaching time to specific exam preparation, especially in the areas of communication and consultation skills.
Facilitate peer support and group learning.
Reflection in medical education has been defined as ‘a metacognitive process that occurs before, during and after situations with the purpose of developing greater understanding of both the self and the situation so that future encounters with the situation are informed from previous encounters.’33 There is an increasing emphasis on reflective practice in medical education. Reflective practice can improve skills in professionalism and clinical reasoning, and lead to better patient management.
Genuine reflective practice may be a new concept to many IMGs – they may simply never have been encouraged to stop and reflect on their practice and performance in the past. But self-reflection is a skill that can be fostered during a registrar’s training.34
Encourage reflective practice using discomfort logs, journaling, case discussions etc.
While delivery of feedback can be challenging in any circumstance, there are specific issues for IMGs that can make this even more challenging. These include the perceived power dynamics between teacher and learner, communication issues, attitudes towards critique, and potential vulnerability in evaluation. In many cultures, critique is not a usual part of day-today practice and can therefore be misconstrued as evidence of a serious failure. Indeed, feedback has been more often associated with loss of face, shame and embarrassment in IMGs than other registrars.2
Ask your registrar about their previous education and training and how feedback was given. How has their performance been evaluated in previous learning situations? What type of feedback are they familiar with? How do they find receiving feedback?
Explicitly discuss the nature and process for feedback in the practice (regular, frank, supportive).
Establish a good relationship with your registrar based on respect, trust, transparency and openness at the beginning of the placement to provide a sound base for constructive feedback.
Invite feedback on your own performance as a supervisor to help normalise this in the practice.
Recognising one’s limitations and appropriate help-seeking is a core general practice skill, and a fundamental aspect of safe practice. It is also essential for effective learning. However, 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.
Ask your registrar about their comfort with calling for help.
Explicitly discuss the nature and process for help-seeking in the practice i.e. when to call, how to call.
Review a ‘call for help’ list at the commencement of the practice.
General practice training is a demanding and potentially stressful experience for all registrars. It requires them to balance work, family, study and other demands. However, for many IMGs, the 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. As previously discussed, 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).
Personal issues may impact significantly on a registrar’s performance and motivation to study. Supervisors should therefore explore such issues with their IMG registrar at the commencement of term and regularly throughout.
Date reviewed: 07 September 2023
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