Assisting international medical graduates applying for their first post in the UK: what should be done?

The number of international medical graduates (IMGs) passing the Professional and Linguistic Assessment Board (PLAB) examination was six times greater in 2004 than in 2000. This has resulted in unprecedented numbers of applicants for junior posts, with some attracting over 1,000 overseas graduates. The Royal College of Physicians working group on IMGs was established in 2004 to address the problems that face newly qualified IMGs. The group has ascertained and now publishes current levels of competition for junior posts in order to inform overseas graduates of the levels of competition they are likely to encounter. The group is seeking ways of selecting applicants when such large numbers apply for posts and is looking at ways of improving clinical attachments. The paper considers these and other difficulties that IMGs face when they first seek employment in the UK and discusses possible solutions.     

International medical graduates: lessons from the past and hopes for the future

The high levels of unemployment among international medical graduates (IMGs) in the UK and the skewed career structure of the NHS may stem from the 1930 withdrawal of General Medical Council recognition for Indian degrees forcing Indian colleges to align more closely with Western medical practices. From 2001 emigration to the UK surged just when UK medical schools were increasing their output. The result was severe unemployment among IMGs. The visa restrictions put in place to correct this make it difficult for IMGs to come to the UK even for short periods of experience. However, the Medical Training Initiative visa category offers an alternative and allows them the opportunity to gain up to two years' UK experience. The NHS has been in debt to IMGs and the countries that trained them since its inception. We must look for new ways to maintain international links and for the NHS to play a positive role in the global health economy.     

Integrating international medical graduates into the physician-scientist pool: solution to the problem of decreasing physician-scientists in the United States.

There is an increasing shortage of physician-scientists in the United States, threatening future medical research. There are several factors that dissuade US medical graduates from entering into physician scientists careers. This article proposes that international medical graduates (IMGs) who have contributed to the physician work force in the under serviced rural health system could also be a great source to meet the increasing physician-scientist demand. Mechanisms to allow IMGs to enter into the physician-scientist career track in the United States are suggested.     

Relationship Between Performance on the NBME® Comprehensive Clinical Science Self-Assessment and USMLE® Step 2 Clinical Knowledge for USMGs and IMGs

Background: The Comprehensive Clinical Science Self-Assessment (CCSSA) is a web-administered multiple-choice examination that includes content that is typically covered during the core clinical clerkships in medical school. Because the content of CCSSA items resembles the content of the items on Step 2 Clinical Knowledge (CK), CCSSA is intended to be a tool for students to help assess whether they are prepared for Step 2 CK and to become familiar with its content, format, and pacing. Purposes: This study examined the relationship between performance on the National Board of Medical Examiners® CCSSA and performance on the United States Medical Licensing Examination® Step 2 CK for U.S./Canadian (USMGs) and international medical school students/graduates (IMGs). Methods: The study included 9,789 participants who took CCSSA prior to their first Step 2 CK attempt. Linear and logistic regression analyses investigated the relationship between CCSSA performance and performance on Step 2 CK for both USMGs and IMGs. Results: CCSSA scores explained 58% of the variation in first Step 2 CK scores for USMGs and 60% of the variation for IMGs; the relationship was somewhat different for the two groups as indicated by statistically different intercepts and slopes for the regression lines based on each group. Logistic regression results showed that examinees in both groups with low scores on CCSSA were at a higher risk of failing their first Step 2 CK attempt. Conclusions: Results suggest that CCSSA can provide students with a valuable practice tool and a realistic self-assessment of their readiness to take Step 2 CK.     

Opportunities for emergency medicine training in Australia.

Opportunities exist for graduates from the United Kingdom to undertake some of their emergency medicine training in Australia. Guidelines for graduates are presented on when to travel, how to find a position, what information one should obtain about a position, and how to acquire the necessary visa and medical registration. A successful visit takes some time to plan and requires cooperation between the negotiating parties. The graduate who undertakes training abroad can expect to benefit professionally and personally. The development of an international exchange network for trainees would streamline the process and broaden the appeal to graduates of completing some of their emergency medicine training in another country.     

Contributions of International Medical Graduates to US Biomedical Research: The Experience of US Medical Schools.

International medical graduates (IMGs) constitute an appreciable fraction of full-time faculty at US medical schools and of principal investigators (PIs) on National Institutes of Health (NIH) research project grants. Information from the Faculty Roster of the Association of American Medical Colleges (AAMC) and from the NIH Consolidated Grant Applicant File (CGAF) was examined to assess IMGs' contribution to US medical school faculty and research. The study found that the number of IMG full-time faculty more than doubled over two decades-from 7,866 individuals in 1984 to 17,085 individuals in 2004, but that IMGs remained relatively stable as a share of physician full-time faculty (from 18.8 to 19.4%); the share is somewhat higher (20.0% of full-time physician faculty in 1984 to 23.7% in 2004) if faculty with degrees of unknown provenance are included. From 1984 to 2004, IMGs increased as a share of full-time physician faculty who are principal investigators on NIH research grants from 16.5% (540) to 21.3% (1,143). Including faculty with incomplete data on degree provenance, the corresponding IMG share increases to 18.0 and 24.0% respectively. Thus, IMGs comprise at least one-fifth and more likely one-fourth of all full-time faculty physicians who are PIs on NIH research project grants. The proportion of IMG full-time physician faculty who are in basic science departments is about twice that of their US/Canadian counterparts, as is the proportion of IMG physician PIs. Slightly fewer than half (48%) of full-time IMG faculty PIs pursue human subjects research (as coded by the NIH), while the majority of US/Canadian counterparts pursue human subjects research.     

A survey on the graduates from the combined emergency medicine/pediatric residency programs

The guidelines for dual training in Emergency Medicine (EM) and Pediatrics over a 5-year program have long existed. Many have questioned the benefit of such training in relation to either specialty and in relation to Pediatric Emergency Medicine (PEM) sub-specialty training. We report on the professional outcome, career focus, and job satisfaction of these graduates. Surveys were returned from 91% (n = 29) of graduates, all of whom reported completing either of the two combined training programs. All respondents reported practicing in an emergency medicine setting either with or without an additional pediatric emphasis. Fifty-nine percent reported an academic EM affiliation. Almost all (96.5%) would choose to repeat combined training and all reported they would recommend the combined program to medical students interested in Pediatrics and EM. Combined graduates report a high level of satisfaction with their training and overwhelmingly would recommend such training to medical students. Combined graduates seem to universally work in an ED setting, although a number maintain their pediatric involvement. Over half of the graduates participate in academic EM.     

An overlooked source of physician-scientists.

A shortage of physician-scientists in the United States is an ongoing problem. Various recommendations have been made to address this issue; however, none of them have ameliorated the situation. Foreign medical school graduates with postdoctoral training in the United States are an overlooked and untapped resource for combating the dearth of physician-scientists. Evaluation of the scientific staff at the University of Texas Southwestern Medical Center revealed that 11% of all postdoctoral fellows were international medical graduates. Interestingly, a survey taken by these individuals revealed a lack of institutional and/or mentor support for career development and preparation for becoming physician-scientists. Foreign postdoctoral fellows with medical degrees are not even eligible for physician-scientist grants and awards since they are not US citizens. Although physicians educated in the United States usually matriculate from medical school with high educational debt that prevents most of them from entering into scientific careers, doctors trained outside the United States generally have minimal, if any, debt. Furthermore, many of them have a keen interest in remaining in the United States once they complete their postdoctoral training. Thus, foreign-trained medical professionals who have pursued scientific training in the United States can be one of the solutions for the current dearth of physician-scientists.     

Validation of a large-scale clinical examination for international medical graduates

Objective

To evaluate a new examination process for international medical graduates (IMGs) to ensure that it is able to reliably assign candidates to 1 of 4 competency levels, and to determine if a global rating scale can accurately stratify examinees into 4 levels of learners: clerks, first-year residents, second-year residents, or practice ready.

Design

Validation study evaluating a 12-station objective structured clinical examination.

Setting

Ontario.

Participants

A total of 846 IMGs, and an additional 63 randomly selected volunteers from 2 groups: third-year clinical clerks (n = 42) and first-year family medicine residents (n = 21).

Main outcome measures

The accuracy of the stratification of the examinees into learner levels, the impact of the patient-encounter ratings and postencounter oral questions, and between-group differences in total score.

Results

Reliability of the patient-encounter scores, postencounter oral question scores, and the total between-group difference scores was 0.93, 0.88, and 0.76, respectively. Third-year clerks scored the lowest, followed by the IMGs. First-year residents scored highest for all 3 scores. Analysis of variance demonstrated significant between-group differences for all 3 scores (P < .05). Postencounter oral question scores differentiated among all 3 groups.

Conclusion

Clinical examination scores were capable of differentiating among the 3 groups. As a group, the IMGs seemed to be less competent than the first-year family medicine residents and more competent than the third-year clerks. The scores generated by the postencounter oral questions were the most effective in differentiating between the 2 training levels and among the 3 groups of test takers.     

A comprehensive ED orientation for new graduates in the emergency department: The 4-year experience of one canadian teaching hospital

Based on our experience, a structured orientation program can prepare new graduate nurses to function competently in an emergency department with a satisfactory sense of self-efficacy. A combination of classroom and clinical learning has reduced nurse vacancy rates and accelerated entry into the staffing of the emergency department. Thus far, the retention rates of the graduates of our program are above average for the hospital. We suggest that having colleagues at work, making good friends in the department, celebrating birthdays and holidays, and knowing that there is someone at work available to talk to about concerns or difficulties provides support for the orientees.We were able to identify a number of factors that are important to the success of our program. For example, our careful selection of preceptors with good communication skills who had experience both in general and ED nursing and a commitment to teaching facilitated the orientation process. We found that having the preceptors follow the same orientees over the length of the orientation provided continuity for the orientees.The new graduates benefited by being introduced to the emergency department at the start of their orientation with a gradual increase in their patient responsibilities. Weekly meetings lasting an hour were held in the ED conference room and involved the ED educator, preceptors, and orientees. These meetings helped to resolve issues early and to track the orientees' progress.The preceptors and new graduates gave their weekly feedback forms to the educator. The forms were not anonymous, but they provided an outlet for comments, problems, and suggestions that the educator followed up on, and changes to the program were made on the basis of the feedback provided. The forms also provided a safe and productive opportunity for the participants to vent their feelings and review small issues.We have 4 nurses in our orientation program at one time and recommend that the number of students be limited to this number. The orientation requires a great deal of dedication and hard work not only by the preceptors and educators but also by the entire staff, who must acquaint themselves with and welcome new staff and provide support to them during the shifts.

The retention rates of the graduates of our program are above average for the hospital.

The new graduates found it difficult in the first few months after orientation as the relative security of orientation ended, but they saw themselves as contributing members of the ED team. They reported that the support from the staff continued to be high and readily available and that they would recommend the program to other new graduates.

Future development

In future programs, we will give the questionnaires previously described to measure self-efficacy and employee attitudes both before and after completion of the orientation program. As our orientation program continues to develop, we plan to include peers in the hiring and interviewing process to help ensure compatibility of the applicants with the unit work environment.As our hospital administration has viewed the results of the program, they have been convinced of its worth. A review of costs is planned for the future. The Nursing Executive Center estimates that the total cost of such a program will be equal to or less than the cost of traditional specialty orientation programs (where nurses begin their training on a medical or surgical floor), because there will be a more rapid entry of new nurses into the staffing mix.[6]     

Establishing a training programme for rehabilitation aides in Haiti: Successes,challenges, and dilemmas

Background.?In Haiti, there are scarce resources available for physical rehabilitation. Healing Hands for Haiti International Foundation has established a rehabilitation aide programme as a means of providing rehabilitation services. This article illustrates some of the successes, challenges, and dilemmas that arise in the provision of such an education.

Methods.?Graduates and students answered a 23-item questionnaire designed to investigate respondents' perceptions of the training programme. These responses were then coded and quantified for analysis.

Results.?The author interviewed 32 of 49 graduates and current students. Forty-five percent of graduates were working as rehabilitation aides, and the majority of those were working in urban areas. Graduate's earnings differed greatly. Respondents suggested that the programme needed to help the graduates find employment after graduation and to provide continuing training. The most common limitation in education mentioned by the graduates was a need for basic nursing skills and first-aid education.

Conclusion.?The most common difficulties and dilemmas in providing a rehabilitation aide programme were: lack of resources including job opportunities for graduates, and lack of proper support available from supervising healthcare providers. Curricula for similar programs must be culturally sensitive, help create employment opportunities, and provide continuing educational opportunities for their graduates.     

A mentor development program for clinical translational science faculty leads to sustained, improved confidence in mentoring skills

Mentorship is crucial for academic productivity and advancement for clinical and translational (CT) science faculty. However, little is known about the long-term effects of mentor training programs. The University of California, San Francisco (UCSF), Clinical and Translational Science Institute launched a Mentor Development Program (MDP) in 2007 for CT faculty. We report on an evaluation of the first three cohorts of graduates from the MDP. In 2010, all Mentors in Training (MITs) who completed the MDP from 2007 to 2009 (n= 38) were asked to complete an evaluation of their mentoring skills and knowledge; all MITs (100%) completed the evaluation. Two-thirds of MDP graduates reported that they often apply knowledge, attitudes, or skills obtained in the MDP to their mentoring. Nearly all graduates (97%) considered being a mentor important to their career satisfaction. Graduates were also asked about the MDP's impact on specific mentoring skills; 95% agreed that the MDP helped them to become a better mentor and to focus their mentoring goals. We also describe a number of new initiatives to support mentoring at UCSF that have evolved from the MDP. To our knowledge, this is the first evaluation of the long-term impact of a mentor training program for CT researchers.     

Recertification in the medical specialties: a way forward

Revalidation will have two core components: relicensure and specialist recertification. All doctors wishing to practise in the UK will require a licence issued by the General Medical Council and those on the specialist register will also be required to demonstrate that they meet the standards that apply to their medical specialty. Eight methods of evaluating performance are considered in this paper--all provide opportunities to reflect on clinical practice and to raise standards. A blueprint might be used to ensure that relicensure and specialist recertification sample different domains of clinical practice during the five-year cycle, but time and money will be required to develop standards that are valid, reliable and assessable, as well as to pilot and implement the specialty-specific tools required for assessing such standards. The Royal College of Physicians and the medical specialties must engage with this process so that specialist recertification is acceptable and achievable.     

Legal implications of evaluation procedures for students in healthcare professions.

Evaluation of students is an integral part of teaching and instruction. Evaluations take on added dimensions when students are enrolled in healthcare training programs, such as nurse anesthesia. Not only must students master a body of knowledge, but they also must be able to integrate, process, and apply this knowledge appropriately in a clinical setting on a human patient. Thus, societal and legal issues enter into the training and credentialing of a healthcare practitioner. Conversely, today's students are more aware of their rights and freedoms and are more willing to appeal to the legal system for satisfaction of their grievances. Thus, evaluation must meet many needs; most important, evaluation must be fair and objective for society, school, and the student. In order to develop and implement a just evaluation system, instructors and administrators should be cognizant of the legal parameters and ramifications of evaluation processes.     

Imbalance of distribution of physicians in the Arab world

The Arab world, as a whole, now has 8.5 medical doctors per 10,000 population. This average covers a great diversity of national situations; for example 0.6 doctors per 10,000 population in Somalia, and 17.5 doctors per 10,000 population in Qatar. From the viewpoint of medical staffing, the Arab countries can be grouped into four categories: (i) Countries with low medical density: their national staff is scarce, they do not have a long academic tradition, and they have to rely on foreign physicians (Yemen, Djibouti, Somalia, Mauritania). (ii) Countries with acceptable medical density: they have strengthened their medical training system during the last decades, their production of medical graduates is now fairly high, and there is seemingly a threat of oversupply (Algeria, Tunisia, Syria, Iraq). (iii) Countries with relatively high medical density: their medical staffing is below that of developed countries, but their economic possibilities are reduced, which leads to an oversupply; these countries are exporters of medical manpower (Egypt, Jordan). (iv) Countries that import medical manpower although their own medical density is quite high: their medical training is recent or non-existent and their health system relies to a great extent on foreign doctors (Saudi Arabia, Bahrain, Qatar, United Arab Emirates, Libya, Kuwait). They are all oil producers. In brief, a shortage and an oversupply of medical doctors coexist in the Arab world, and concerted action is required.