Learning in a foreign land: The hidden curriculum of practice

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Learning in a foreign land The hidden curriculum
of practice

• Jocelyn Lockyer
• Herta Fidler
• James Keefe
• Chris de Gara

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Disclosure

• This project was funded through the Integrated
  Health and Learning Project, a mentoring
  feasibility initiative, with support from
• Advanced Education and Technology
• Alberta Health and Wellness
• University of Alberta
• Ethicon Johnson and Johnson

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Background

• 23.1 of physicians in Canada received medical
  school training outside of Canada and US
• 43.4 of these physicians will be from
  lower-income countries (e.g., S Africa, India)
• Each province has unique approaches to
  recruitment, orientation, mentorship, and
  retention

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IMG Physicians in Alberta

• Enter on PART V license
• Restricts scope and geographic location of
  practice
• 2 week orientation/assessment in one community
• Enter practice in another community in Region
• Require Cdn examinations to move along (MCC,
  CFPC/RCPSC)

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Previous Studies

• IMGs
• Canadian examinations
• Learning to succeed at clinical work
• Disease profiles, medications, investigations,
  referral practices, privileges
• MD as person with family issues
• Data was incompleteonly portrayed the IMG
  perspective, not the perspective of the MD
  leaders
• Lockyer J et al. Journal of Continuing Education
  in the Health Professions 2007 3, 157-163
• Klein D et al. Family Medicine 2009 41(3) In
  Press.

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Research Question

• Do IMGs and physician leaders have a common
  understanding about clinical learning needs faced
  by physicians new to Canada?

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Methods

• 10 Face/face interviews with physician leaders
  (trustees) Regions CPSA Hospital Medical Staff
• Focus groups with 23 IMGs in 6/7 rural Regions

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MethodsInterview/Focus Group Protocol

• Transition issues faced
• clinical management of common diseases
• laboratory medicine and diagnostic imaging
  protocols
• referral
• privileging
• billing and insurance systems.

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MethodsData Handling

• Interviews and focus groups were audio recorded
  and transcribed
• Transcripts read independently (HF,JL)
• Coding structure for themes and subthemes
  determined and applied to transcript data (MC)
• Data reviewed again
• Core concept determined
• Data reviewed again
• Interviewer read m/s to verify interpretation of
  findings

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Ethics

• Ethics Boards at
• University of Alberta
• University of Calgary

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Results

• Key theme Concordance/discordance
• Concordance
• Learning is required to work effectively in
  Canadian setting

• Trustee I think that there are multiple
  challengesThere's likelihood of a completely
  different system set and practice set, different
  processes, different relationships, cultural
  adjustments with regions, with colleagues. (I-5)

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Results Discordance

• Trustee
• IMG could learn once were told or shown what
  to do
• We have an introduction package for all locums
  and new docs that tell them how orders should be
  written, what abbreviations to use, to print
  block print, write neatly. We have all sorts of
  things that we tell them to do, unfortunately
  most of them dont comply. (I-10)
• Failed to recognize the magnitude of the learning
  tasks

• IMGs
• Struggled to calibrate their performance with
  standards of performance which were implicit and
  unclear and not always accessible
• Learned through feedback, questions from
  patients, mistakes
• So eventually most of it you pick it upYou learn
  every day, new challenges every day.

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Results Standards of Practice

• Trustee where we do see deficiencies is
  chronic disease management I would say that the
  more emergent nations where many of our IMGs come
  from do not have standardized management for the
  variety of conditions that we have clinical
  practice guidelines about. And so, physicians
  need some help to understand the value and to
  adopt them into their practices because they make
  life so much easier. (I-4)

• IMG . I like working with a system. So if a
  patient had diabetes I find that over here
  everybody just uses whatever they like, there's
  no real system as to what is first line drugs
  that you use and what do you add if that doesn't
  control it well. So I think something like a
  brochure or something just outlining the Canadian
  recommendations as to what is first line therapy
  and what to add. (FG-C)

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Results--Investigations

• Trustee But in broad strokes you could say
  sometimes people just order every lab test on
  everybody that walks in the door. And I've seen
  that in this region too where a couple of IMGs
  ordered everything on everybody And it took a
  pathologist talking to them to give them a little
  tune up to smarten them up on what was
  essentially bad ordering practices. And what they
  were doing was cover your butt medicine as they
  understood that maybe it should be, but it was
  just poorly chosen tests. (I-7)

• IMG So before you even order an investigation
  (in home country), you need to know why you're
  ordering the investigation We don't have the
  resources, so you really try and maximize what
  you do have, so any investigation that you order
  there has to be a valid reason. I find that a
  lot more investigations are done here I'm not
  saying not for valid reasons but more as a to
  save my butt Not from a clinical aspect, but its
  from a litigious. And I found that quite
  different. (FG-F)

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Results Referrals

• Trustee Also a big one is when to refer. They
  seem to either hold on or keep or refer. Because
  a lot of times they haven't had the same
  specialists back at, so they don't know how to
  integrate specialists and keep people you think
  what the heck are they keeping that person with
  chest pain for. (I-1)

• IMG So you find yourself bouncing back and
  forth. Everybody sending you back and forth...
  there's no standardization in terms of format of
  referring patients But generally everybody has
  to have a letter, we understand that. But some
  specialists will want you to phone in first and
  discuss. Some would want you to send in a letter
  first and that is a real big frustrating because
  some of them you send letters to and there's no
  response a long time and you don't know what
  happened and you end up forgetting sometimes.
  (FG-D)

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Privileges

• Trustee Sometimes I find that extremely
  challenging because IMGs lack the understanding
  of the scrutiny that the credential process is
  put through in Canada. They figure they can
  just... do all sorts of procedures and thats
  something difficult for them to understand that
  no, if youre working in a larger centre and
  specialists are around that you often have to
  decline those procedures to the specialists. (I-2)

• IMG Like you don't mess with things that you
  shouldn't be messing with. Not because you don't
  have the capability, but because maybe someone
  else will handle it much better. The only problem
  I have with this is for instance, if the
  specialist is out of town, you are expected to
  know how to do it or to still remember how to do
  it. . It happened to me recently where I had a
  patient who almost bled to death.. and I had
  never used the equipment that we use here for
  central lines. (FG-D)

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Mediating influences

• 2/6 regions had orientation programs
• Some clinics had
• lists of consultants
• Information about lab/diagnostic imaging
• Some towns
• Other people clinic personnel, realtors,
  physician-partners
• Other MDs

• IMG I was lucky enough to walk into a clinic
  where there was two other senior doctors who had
  been here, also South African immigrants, who had
  been here, the one been here 8 years and other
  one 5 years at that point or 4 years. So, and we
  all kind of lived close together and they
  socially supported us very well, so they were
  showing us the ropes in every way and basically
  mentoring us in the practice. (FG-B)

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Discussion

• Identified similar learning challenges
• Perceptions differed on
• the magnitude of the learning issues being faced
• the ease/difficulty of learning new approaches to
  meet new standards of care, particularly when the
  standards appeared to be implicit

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Discussion

• Trustees
• Recognized learning needs
• Believe solutions lie in
• Short explanations
• Lists
• Directions
• Saw learning as a series of isolated learning
  tasks
• Did not see that learning carried a cumulative
  load associated with trying to learn many things
  in a short period

• For IMG learning requires
• New knowledge and skills
• Codified (invisible guidelines)
• Tacit
• Complex learning
• Example Chronic disease--ASTHMA
• Diagnostic tests for asthma (peak flow meter)
• Referral to an asthma clinic referral protocol
  and specific information
• Medications (new names, new medications)
• Protocol for monitoring and follow-up

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Conclusions

• IMGs face many challenges not fully understood by
  medical leadership.
• Attention needs to be paid to individual
  physicians new to Canada to
• discern their knowledge base
• Identify the gap between the practices learned
  elsewhere and Canadian expectations
• to create individualized and group educational
  and support programs.
• It is unlikely that physicians can efficiently
  and effectively learn to meet standards of
  practice without guidance and support.

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Study Limitations and Implications

• Limitations
• Small group of trustees and IMGs in one province
  in Canada.
• Implications
• Need to address learning needs of physicians new
  to Canada
• Continuing to recruit to meet MD shortages across
  Canada
• Large groups of Canadian citizens studying
  medicine outside of Canada
• Educational programs are needed to help MDs with
  transition at a clinical level and a personal
  level
• patient management
• patient expectations
• system expectations
• approaches to working with other physicians and
  health care providers.

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Above all there is the human side

• IMG I remember Sundays were the worst. Sundays,
  I was used to going to a specific church and I
  went for years and thats the way that it wasAnd
  I remember the first 6 weeks. Sundays after
  being in church, when we got home, my wife and
  myself went into the bedroom. We held each other
  and we cried. We didnt do it in front of the
  children. But that, that was what we were doing
  and weve got to make this work. But we missed
  our church and our church community and the
  backing from the church and finding people here.
  (FG-E)