2007; 29: 427–430

TWELVE TIPS

Twelve tips for developing training programs forinternational medical graduates

GEOFF COUSER

Royal Hobart Hospital, Hobart, Tasmania, Australia

Abstract

Background: International Medical Graduates (IMGs) are a diverse group of doctors who provide essential health services in many

western countries, and hospitals are increasingly relying upon IMGs to fill vacancies in all staff grades. Clinical skills and experience

vary greatly between doctors, and orientation and clinical skills training is a way of addressing any identified deficiencies.

Work done: This paper relates the experiences of establishing a training program and support services for IMGs working in the

public hospital system in Tasmania, Australia, and offers advice for other agencies contemplating establishing similar programs.

Conclusions: A ‘hub and spoke’ model is a useful model to adopt: a central coordinating office designs and implements programs

informed by best available evidence, and clinical educators on site at healthcare facilities implement programs and provide direct

assistance and orientation. Broad-based programs attending to orientation, doctor’s families’ needs, communication skills and

clinical skills training are required. Support from health administrators is essential.

Introduction

International medical graduates comprise between 23% and

28% of the medical workforce in Australia, Canada, the

United Kingdom and the United States (Mullan 2005). In

Australia, international medical graduates (IMG’s, also

referred to as overseas trained doctors, OTDs) comprise of

up to 30% of the public hospital workforce providing

essential clinical services (Australian Medical Workforce

Advisory Committee 2004). This figure is steadily growing

as the health workforce grows disproportionately to the

number of graduates from Australian medical schools. Once

in Australia, this group of doctors and their families face

substantial challenges in adjusting to new communities and

clinical practices. Hence, overseas trained doctors have

specific training requirements above and beyond local

graduates with respect to orientation, communication and

clinical skills training (Sandhu 2005; McGrath 2004). For this

reason many jurisdictions have established specific support

and training programs to assist OTDs with adjusting to their

new workplace and communities (Heal & Jacobs 2005).

This has occurred in the context of increasing scrutiny of

this heterogeneous group of doctors. In Australia, IMGs have

attracted a great deal of media and political attention in

response to some high profile cases (Birrell & Schwartz

2005). As a result, administrators, educational supervisors

and the doctors themselves have been brought under

immense pressure to provide evidence of continuing

medical education and proof of competencies. Challenges

relating to morale and providing support to IMGs in the face

of misplaced public scepticism remain.

This paper arises from observations made by the author’s

experiences in developing and managing a program for IMGs in

Tasmania, Australia. The program is designed to address the

learning needs of pre-vocational IMGs working in the

Tasmanian public hospital system. A tutorial program and

clinical workshops are provided both during working hours and

after hours as part of the hospital’s orientation and continuing

education program. Additionally, specific cultural and orienta-

tion support is provided to IMGs of all grades who request it.

As IMGs arrive throughout the year in response to vacancies in

the hospital system, a rolling program has been developed.

Completion of the program in its current form does not

imply competency; but does assist in preparation for the

Australian Medical Council clinical exams which are used for

that purpose and leads to unconditional registration in

Australia. Different regions will have different training

priorities and needs, and the following tips are provided as a

guide to educators developing similar programs.

Practice points

. Understand the practices and certification requirements

of your jurisdiction.

. Involve IMGs with the planning and implementation of

programs.

. Consider the needs of spouses and families.

. Orientation to health systems is of paramount

importance.

Correspondence: Dr Geoff Couser, Department of Emergency Medicine, Royal Hobart Hospital, Hobart, Tasmania, Australia. Tel: 61 3 6222 8609;

email: geoffrey.couser@dhhs.tas.gov.au

ISSN 0142–159X print/ISSN 1466–187X online/07/050427–4 � 2007 Informa UK Ltd. 427DOI: 10.1080/01421590701317843

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Tip 1

Understand the program participants

The demographics of international medical graduates are

rapidly changing and it is essential that educators understand

this change in recruitment and migration. Australia has, in the

past, attracted graduates from medical schools in countries

with similar models to local training methods and practice.

This made orientation and training relatively easy for hospitals.

Since the mid-1990s there have been an increasing number of

doctors coming from countries with different training schemes,

different disease profiles and different clinical practice models

to those in Australia. This has implications for educators in

designing practical orientation programs and transparent

assessment tools. It has been recognised that increased

resources need to be assigned to allow for the development

of such programs. Pre-work assessments allow for the

documentation of existing knowledge, skills and attitudes

and allow for targeted training and orientation to be delivered.

Similarly, surveying the workforce to understand diverse

backgrounds and cultural needs can be of immense benefit.

Tip 2

Have a defined mission statement

Make it clear to all that the role of the program is to provide

clinical and practical support and training and not to be an

enforcer of standards. It is important to build up trust with the

group of doctors registered with the program and it is essential

that they can speak openly with you about their concerns and

needs. This privilege may be compromised if program

participants suspect that you are also assessing them for

competencies which may be fed back to administration. There

is a role for assessing competencies, but be clear who will do

this before you start your program. Competency assessment is

usually the responsibility of hospital administration.

Tip 3

Acknowledge and build upon prior learning andexperience

IMGs come from diverse backgrounds and bring a great deal

of experience to their new jobs, thereby enriching the cultural

environment of the hospital and the community. For example,

many IMGs in Tasmania have a wealth of experience in

infectious disease and trauma management which local

graduates and workers will never likely experience. This

clinical diversity can bring a range of different perspectives to

clinical problem solving from which local staff can learn a great

deal. Additionally, many IMGs have specialist qualifications

from their home country, yet start work in their new home in

junior resident positions. It is important to harness this

knowledge experience and apply it with sensitivity and

practical rostering, for example, an orthopaedic surgeon

working as a junior resident would be better suited to being

rostered to a surgical rotation when first starting work than say,

a term in psychiatry. Regular contact with rostering staff can

help ease the orientation process for many doctors.

Tip 4

Understand cross-cultural learning styles

It is important to acknowledge that IMGs, like all doctors, have

different learning styles. For example, educators will be aware

that some doctors learn less efficiently in interactive group

settings and may prefer other methods. Many cultural groups

are used to being passive receivers of information delivered in

didactic styles – which is opposite to current trends in western

clinical teaching. Educators involved with training IMGs may

need to modify programs to accommodate a wide range of

learning styles. Training programs for clinical supervisors

should incorporate cultural awareness programs to improve

delivery and to improve learning. Given the internationalisa-

tion of education at a tertiary level around the world,

universities have developed a range of resources which can

assist medical educators in this area.

Tip 5

Understand and integrate the registration, educa-tional, immigration and accreditation requirements ofparticipants in your jurisdiction

Once the targeted workforce is identified, it is necessary to

survey administration, educational bodies and the IMGs

themselves to determine what is required. A number of

organisations have performed similar studies and identified

communication difficulties, orientation, difficulties in clinical

skills, and lack of information about health systems as key

issues for IMGs (Postgraduate Medical Council of Victoria 2002

& Hall et al. 2004). Additionally, involving the IMGs in the

planning and delivery of programs which ultimately affect

and assist them promotes as sense of ownership of the

programs. A working knowledge of current registration

requirements and examination requirements (such as the

Australian Medical Council examination process) is essential so

that appropriate advice and training can be provided. Close

liaison with registration and immigration authorities is essen-

tial, as rules and requirements are inexorably linked and

inevitably change regularly.

Tip 6

Provide relevant and applicable training

Training needs to be relevant and aligned with clinical practice

requirements. This can occur during a structured orientation

program or be offered throughout the year as new employees

arrive. Unlike local graduates who start work at the same time

each year, IMGs tend to arrive throughout the year and

therefore miss the workforce orientation programs traditionally

offered at the beginning of each new calendar year. Flexible

methods of training (such as on-line modules or a mentor

system) need to be considered in these instances.

G. Couser

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An orientation program may include intensive pre-work

training in local practices and skills, often in individualised

programs. As a result many resources need to be

provided to ensure safe practice and transparent assessment.

Additionally, such training should be consistent with the

principles of adult learning: it should be contextual, relevant

and targeted. When communication training is considered,

supervisors need to appreciate that training may be required in

just not conversational language but ‘medical’ language as

well. The Calgary-Cambridge guides provide a useful frame-

work to introduce IMGs to communication styles in western

medical systems (Kurtz et al. 1998).

Tip 7

Relate activities to safety and quality

Safety and quality in healthcare has quite rightly attracted much

interest in recent years, and the provision of adequate orientation

programs and ongoing clinical education should incorporate the

principles and practice of achieving optimal patient safety.

Providing functional instruction on areas such as handover, early

notification of senior staff and working in interdisciplinary teams.

In addition to providing such programs, training programs for

IMGs have the opportunity to liaise with administrators to ensure

that newly arrived doctors are appropriately orientated and are

working in a supportive environment. Regular evaluation of

programs ensures that the curricula developed are consistent

with desired outcomes and contributing to improved patient

care. Our own surveys indicate that creating a culture of support,

teaching and learning leads to improvements in recruitment and

retention rates of IMGs.

Tip 8

Be able to rapidly respond to local needs andchanging requirements

Once the program has been developed and implemented it is

essential that the project be able to respond to new develop-

ments as they arise. For example, the medical administration of

one hospital contacted the project to provide feedback that

many of its IMGs were found to be struggling with medication

issues. The program responded by incorporating practical

pharmacology into a number of tutorials and practice examina-

tions. Programs can be used to disseminate information

concerning current developments, such as infectious disease

trends and public health matters. Seeking regular feedback from

educational supervisors and other stakeholders can ensure that

training programs remain relevant and contemporary.

Tip 9

Engage with existing staff and programs (makefriends, not enemies)

Public hospitals in Australia, like many systems worldwide, are

under a large amount of pressure, and many existing hospital

staff are stretched to provide services beyond direct

service delivery. Programs for IMGs should provide practical

support to supervising clinicians and medical administrators to

help achieve the program’s goals. Identifying educational

supervisors in clinical areas and providing practical guidance

in orientation, advice about specific learning requirements,

and information regarding evaluation can assist such staff

considerably. By engaging with existing hospital staff,

integrating with existing educational programs, and acknowl-

edging what’s already been developed in individual facilities,

the program can not only avoid duplication but can build a

great deal of goodwill and engage with staff in all areas.

Similarly, there are often a number of existing programs in the

region which have applicability to IMGs and it is unnecessary

to duplicate. By introducing yourself to these providers

strengths and gaps can be identified and a coordinated

regional approach to training can be adopted. The project

facilitated a regional forum to identify each stakeholder’s areas

of expertise so that an efficient network of consultation and

referral could be developed.

Tip 10

Provide incentives for participants

Many IMGs are strategic learners: that is, they want to see a

tangible outcome for their efforts. In Australia, passing the

Australian Medical Council clinical examination is a priority so

that full unconditional registration may ultimately be achieved.

Hence, the part of our program which attracts the most interest

is preparation for this national certification exam. It is important

to recognise that not all IMGs are studying for such exams:

many are temporary residents and therefore do not require such

certification. However, they are still likely to require similar

levels of training and orientation. In these circumstances

providing records of attendance at tutorials and courses are

desirable as they can be used in a portfolio to describe

experience and evidence of training for future employers.

Negotiation with employers and registration bodies may be

necessary so that doctors in need of extra assistance can be

identified and mandated to attend additional training.

Tip 11

Provide consistent and accessible information

Developing a working database of participants and maintain-

ing regular contact with each of them allows the program’s

objectives to be met. A regular newsletter can provide clinical

updates and advertise upcoming tutorials and courses; this

should be delivered in both electronic and paper formats.

A web-page allows for information to be regularly updated

and can provide links to a range of external agencies of

interest to IMGs. These can include employment, immigration

and registration information, clinical guideline sites and local

information. However, it should be recognised that internet

access may not be always available, and so alternative

methods of providing information, sometimes using multiple

languages, may be the best way to disseminate important

information. Posters and briefing sheets about the program can

Twelve tips for developing training programs for international medical graduates

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be displayed prominently in common areas in hospitals.

National databases and information should be used where

possible, such as the DoctorConnect site in Australia (http://

www.doctorconnect.gov.au). For an example of useful

web links of relevance in Tasmania, Australia, see Table 1

on Medical Teacher Website (www.medicalteacher.org).

Tip 12

Look after the doctors’ families

Moving to a new country and culture can be difficult for

not just doctors but their families as well; for the doctor

employment provides at least some opportunities for social

interaction whilst the spouse and children can be left to

struggle with settling in to a new environment, often in

isolation. Providing information and support for families

in terms of day-to-day living advice (such as banking,

accommodation and obtaining a driving licence), finding

accommodation and schools and introductions to local cultural

groups can not only provide much-needed practical assistance

but can enhance the settlement process for all concerned.

Providing such support can improve the experience for the

doctor and make life in a new country much easier.

Conclusion

Designing programs for IMGs is a complex task, and

programs must be tailored to individuals and local conditions.

Being flexible and being able to rapidly incorporate changing

priorities into programs is essential. Attention should be paid

to not just clinical issues but on broader issues such as

communication, clinical governance and family and commu-

nity requirements. A coordinated regional approach reduces

duplication and can incorporate current best practices from

other jurisdictions, but at the same time, engaging with local

staff to deliver programs directly is of paramount importance

so that overall outcomes can be successfully achieved.

Notes on contributor

DR GEOFF COUSER is an emergency physician at the Royal Hobart

Hospital in Tasmania, Australia, and a Clinical Senior Lecturer at the

University of Tasmania. His teaching interests lie in integrating medical

sciences with clinical practice. He was formerly the director for the

Overseas Trained Doctors Project at the Postgraduate Medical Institute of

Tasmania.

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