|ORIGINAL RESEARCH PAPER
|Year : 2009 | Volume
| Issue : 3 | Page : 344
The Observer Program: Insights from International Medical Graduates
P McGrath, D Henderson
International Program of Psycho-Social Health Research, Central Queensland University, Milton, Brisbane, Queensland, Australia
|Date of Submission||21-Apr-2009|
|Date of Acceptance||22-Sep-2009|
|Date of Web Publication||03-Dec-2009|
PO Box 1307, Kenmore, Queensland 4069
Source of Support: None, Conflict of Interest: None
Context: This paper presents the findings of qualitative research documenting the experiences in the Observer Program (OP) from the perspectives of international medical graduates (IMGs) entering the Australian healthcare system.
Objectives: To examine the experience of IMGs participating in the OP.
Methods: In-depth, open-ended interviews were conducted with nine IMGs who had been part of the OP.
Findings: The feedback provided by the IMG participants about the OP was overwhelmingly positive. Participants identified a strong need for such a program, both from the perspective of increasing their confidence and competence and integrating them into and lifting their status within the Australian healthcare system. Positive outcomes reported to result from the program included increased confidence as a doctor in Australia, development of a sound knowledge of the Australian medical system, including basic medications used in local practice, familiarity with appropriate paperwork and the specialties of particular physicians, increased experience, refreshment of existing clinical skills and the opportunity to learn Australian idioms. However, some participants related difficulties created by their unpaid tenure whilst undergoing the program, as well as difficulties in relationships with particular supervising physicians within the program.
Discussion: Findings provide insights into a hospital-based educational initiative designed to integrate IMGs into the Australian healthcare system.
Conclusions: Responses from participants offer practical insights into the need for, strengths, weaknesses and outcomes of the OP.
Keywords: Observer Program, international medical graduates, qualitative research, Australian healthcare system
|How to cite this article:|
McGrath P, Henderson D. The Observer Program: Insights from International Medical Graduates. Educ Health 2009;22:344
Australia has now become increasingly reliant on international medical graduates (IMGs) – doctors who have obtained their primary medical qualification elsewhere – to sustain the healthcare workforce (Heal & Jacobs, 2005; McGrath, 2004). Indeed, IMGs presently account for 25 percent of the total workforce of Australian physicians (Pilotto et al., 2007; Pincock, 2007), the majority of which are in general practice (Heal & Jacobs, 2005).
IMGs are a very diverse group, with variable needs for training and updating skills (McGrath, 2004; PMCV, 2002; CPMEC, 2004). It is essential for the effective integration of IMGs into the Australian health workforce that they are appropriately clinically trained and have a sound knowledge of the healthcare system. However, to date, there has been scant attention to the education or training of IMGs. This article addresses this gap in the literature by presenting findings from research that documented IMGs’ perceptions of their involvement in the Observer Program (‘OP’), a hospital-based pre-employment program for IMGs conducted in the Department of Medicine at the Redland Hospital, Queensland, Australia (‘Hospital’).
The OP was developed as an initiative in response to the need to recruit junior level staff and to ensure that they had adequate theoretical and practical knowledge. The OP provides the opportunity for IMGs to explore clinical and health systems knowledge and practice as an unpaid ‘observer’ in a supported hospital learning environment. It also provides the Hospital with an opportunity to closely monitor the IMGs’ progress and assess their suitability for full-time employment.
The OP originated in the Department of Medicine in 1999. It was subsequently adopted as a hospital-wide recruitment program in 2007. This study presents a focus on the OP during its management by the Department of Medicine and records the experience of 9 of 10 OP participants. Participants in the program run by the Department of Medicine were selected from IMG applicants for junior medical staff positions at the Hospital. The applicants were interviewed with a particular emphasis on knowledge, experience and motivation, which included preparedness to work on a full-time basis (seven to eight hours a day, four to five days a week), without pay and in a junior position. Those who accepted were attached to the Department of Medicine and encouraged to participate in the activities and work of the department. Clinical participation was initially limited to observation, but patient contact was encouraged and progressively increased as the capacity of the doctors was observed to improve. These activities were carried out under the supervision of consultants and senior grade junior staff (registrars). The participants also had contact with and input from other members of the clinical team including interns, pharmacists, nurses and allied health professionals. The conduct of the doctors was governed by a simple agreement that described the permitted activities and their responsibilities. Their involvement was similar to that of senior students, but with a greater emphasis on learning by participation in work. When it was considered appropriate, the doctors were recommended for conditional registration and employed as junior medical staff. The program was managed as part of the normal recruitment and training processes of the department, with no additional funds provided by Queensland Health to support this activity. The program was not actively promoted outside the Hospital, but there was evidence that the Hospital had developed a good reputation for this program among the IMG network.
The study, funded by an Industry Grant, represents collaboration between Central Queensland University (‘University’) and Bayside Health Service District’s Redland Hospital. The aim of the program was to understand the Observer Program from the IMGs’ perspective.
Participants were enrolled through the Project Officer for the study who was under contract with the University and thus independent of the Hospital. The Project Officer was given a list of doctors who had participated in the OP, along with their telephone numbers. This information was obtained from a Hospital representative who had gained verbal consent for this from each potential participant. The participants were consecutively enrolled from this list through an initial telephone call, followed by the Project Officer providing written Project Descriptions of the project and an invitation for voluntary participation in the research. At this stage, signed consent forms from the participants were collected and enrolment occurred. There was no screening of participants. Prior to interviewing, participants were again informed of their ethical rights (e.g. informed consent, confidentiality, right to withdraw). The University Ethics Committee and the Queensland Health Department Human Research Ethics Committee approved the study.
Participants: Participants were IMGs who had been directly involved in the OP. In total, there were 10 IMGs who participated in the OP in the Department of Medicine, of which nine were interviewed for this study. Thus, the participants represent a major sample (90%) of IMGs involved in the OP program when it was run by the Department of Acute Medicine. The most common sample size for this type of work includes between four and 40 participants (Holloway, 2008, p. 213). As Holloway states (p. 181) because of the depth of the research interviews and their analysis, the sample is generally very small. In phenomenological work it is not the number of participants that is important but rather that participants are chosen mainly for their knowledge or an experience of a condition or event (in this case experience with the OP) about which they can inform the researcher (Sandelowski, 1995).
The participants ranged in age from 30 to 46 years, with five males and four females. They came from various countries of origin including China (n=6), Yugoslavia (Bosnia) (n=1), Philippines (n=1) and Sri Lanka (n=1). Because the participants were enrolled from a small, identifiable group at the Hospital, the informed consent procedures gave a strict commitment to confidentiality and a guarantee that no further identifying information would be presented or published with the findings. Hence, further demographic description will not be provided to protect the identity of the participants.
Research Design: An open-ended, exploratory qualitative design was utilised for the study. Qualitative research is used to evaluate programs in healthcare to provide insights on quality and effectiveness and to assist in program improvement (Holloway, 2008; Patton, 2002). Such a qualitative approach is particularly appropriate where little is known about an issue (Krathwohl, 1993; Polit & Hungler, 1995). Thus, it is well-suited to a study on the educational experiences of IMGs where there is scant available research literature.
Interviews: The exploration of the IMGs’ experiences with the OP was conducted through an iterative, qualitative research methodology using open-ended interviews conducted at the time and location of each participant’s choice. The interviews were administered by a psychosocial researcher with a background in cross-cultural research employed by the University and, thus, independent of the Hospital. All interviews were conducted by speaker-phone.
The IMGs were encouraged to talk about their experiences as doctors prior to, during and following their involvement with the OP. A particular focus was on the strengths and weaknesses of the program. The line of questioning included the techniques of probing, paraphrasing and silence to explore each participant's experience (Gaskill et al., 1997). The interviews lasted for approximately one hour and were audio-recorded. They were then transcribed verbatim by a research assistant independent of the Hospital.
Analysis: The language texts were then entered into the QSR NUD*IST (N5 1995) computer program and analysed thematically. All of the participants' comments were coded into ‘free nodes’ which are category files that have not been pre-organised but are ‘freely’ created from the data. The list of codes was then transported to a Word Computer Program (Word 97) and organised under thematic headings. The coding was established by an experienced qualitative researcher and completed by the Project Officer who has extensive experience with coding qualitative data. There was complete agreement on the coding and emergent themes. There were 203 free nodes created from the transcriptions.
Although all Australian IMGs have to pass English proficiency tests, there were language challenges in undertaking the research. During the interviews, the interviewer clarified and repeated any statement that the participant’s accent made difficult to understand. However, in addition to accent, there were grammatical problems with the IMGs spoken responses. In order to remain as faithful as possible to the participant’s insights, the statements have been reported verbatim. At times, however, it has been necessary to correct the grammatical expression in parenthesis to ensure the meaning is easily understood by the reader.
All participants described their experience with the Observer Program (OP) in very positive terms using words such as ‘very good’. As one participant summed up:
- I’m very appreciative for the help from the hospital.
The participants made clear statements that they believed there was a strong need for the OP. A core concern was the need for training for international medical graduates to enable them to obtain sufficient knowledge to integrate successfully into the Australian health system. As one participant explained:
- I mean the thing is absolute - someone comes from another country especially a doctor they were working in their own countries… I mean there are a lot of things that we have to learn to be honest.
The OP was considered necessary to increase the IMGs’ confidence and competence, a benefit for the doctor and the patients for whom they care:
- For myself I think all the training is necessary – you want to practice; you want to practice confidently - competent and confident. Want to be perfect. Good for the patient and good for yourself.
It was also perceived as necessary in order to lift the status of IMGs so that they are viewed by Australian doctors as appropriately trained. Another participant explained:
- You get training from that [OP] and then you get recognized.
For most of the participants the OP was a significant turning point in their efforts to enter the Australian healthcare system:
- Just provides us a chance. You can get into this system quickly.
So there is a strong need perceived for programs such as the OP to ensure IMGs are assisted to enter
- You can’t improve your skills until they [OP] take you. No one will give you a job.
The OP also is important in providing IMGs with an understanding of the level of knowledge of other doctors employed in the Australian hospital system:
- So from that point of view it was very, very useful. I gained the opportunity to see what level of knowledge had the interns [level of knowledge the interns had].
Most importantly, and there was extensive comment on this issue, IMGs perceived a need for the OP in order to understand systems issues. As one participant explained:
- So you have the full view of whole system, so you understand how system functions. It gives you the opportunity to see where you are and where you think you can contribute.
Well-supported by the Hospital team: There were extensive participant statements indicating that a key factor in the success of the OP is the supportive environment provided by the Hospital team of doctors, as can be seen by the following examples:
- The team leaders and the mentors and supervisors were fantastic.
- I just would feel really comfortable there - very supportive.
Good communication and treatment as a team member were noted as important aspects of the support. As one participant explained:
- The communication was fantastic. It wasn’t just the supervisor and myself, but the whole team worked very well. And you were accepted as part of the team.
The approachability of other doctors was also seen as important:
- I could always refer to [other doctors] any time [if] I needed help with any of the procedures or [with] the patient cases. I fully felt free to do that.
Patience, a willingness to spend time with the IMGs and the provision of positive feedback were all seen as particularly helpful:
- Consultants… are very patient; they like to spend time to teach you. I had good feedback which was good and encouraging.
However, the most important positive factor reported about the team of doctors was the respect shown to the IMGs, as attested to in the following statement:
- I think the most, most important thing is the respect.
Lastly, it was noted that one aspect of the Hospital that could have contributed to the supportive environment is that it was a small, regional hospital.
Hands-on experience: A key positive factor highlighted by all of the participants was the opportunity for ‘hands-on’ experience with patients at the Hospital:
- … hands-on, but under supervision, that’s the most important thing.
The participants spoke in detail about the clinical processes they could participate in, including intravenous insertions, involvement in medical rounds, documenting patient charts, arranging for tests (albeit with the Registrar’s signature) and following-up the results, attending the medical clinic with other doctors, writing letters and participating in operations such as caesarean sections. Not only did the participants value the opportunity for ‘hands-on’ experiences, they also highlighted the benefit obtained from the fact these experiences took place in a variety of departments in the Hospital, including the Emergency Department, the Medical Department and the Department of Obstetrics and Gynaecology.
It was noted that although IMGs did not have authority to prescribe drugs or sign paperwork, they could easily ask their supervisors or colleagues to do this for them. Importantly, from their perspective, the IMGs were able to interview patients on their own:
- … the good thing was I was able to see patients on my own.
As one participant outlined, there were strong safeguards in the system as the IMGs would create management plans to be ratified by their supervisors:
- And then after seeing them [patients] and coming up with a management plan and investigation, I would refer them to the team leader at that time who would suggest something else before I actually proceed, which was great.
Comparisons were made to programs in the larger hospitals where IMGs could only observe, with the sentiments of the participants that the OP at the Hospital was superior because of the opportunities to directly interact with patients.
Learning about the broader health system: The participants also pointed out that a significant aspect of the OP’s success is that it allows IMGs to gain an understanding of the Australian healthcare system. As one participant expressed:
- … because it doesn’t matter where you come from, the system is different. So I was able to get used to the system. And to have first whole picture [have an overview of the health system].
Good supervision: Another important factor in the program’s success was reported to be the high quality of supervision provided. For example:
- He’s a very good teacher.
The IMGs practiced with the security that their supervising doctor would check their work:
- And I was allowed to see patients but then he [supervisor] would come and he would see if what I’d done is correct or not.
Most importantly, the IMGs felt that they could easily ask questions if they needed:
- I asked a lot of questions. They were always happy to answer questions.
It was perceived that the willingness to ask questions and the openness to responding reflected the trust inherent in the IMG/supervisor relationships. One participant explained:
- She allowed me [to] work as a resident that way and she knew that if I don’t know something I will ask her. So she had trust in me as well.
Along with trust there was also a positive and encouraging approach seen:
- Very positive and encouraging…
A caveat to this process was that the IMGs were aware that their supervisors were very busy, so they were careful to avoid making excess demands on their time:
- … and I also had to learn how to manage my time because they’re all so busy you don’t want to infringe on them.
Additional educational sessions: As well as good supervision, the IMGs also valued the additional educational sessions they were involved in through the OP.
- He [Medical Director] works very hard on that and they have more education sessions. It’s very good I think so.
The sessions were conducted on a variety of topics, including X-Rays and CT scans and ECGs. The grand rounds were also seen as important educational experiences where the IMGs were exposed to new clinical experiences and felt free to ask questions. They were also allowed to participate in the weekly team meetings and the weekly junior intern and junior doctors’ training. As one participant summed up, all of this provided significant learning experiences:
- I’m always very keen to learn. Going to all the classes and learning new workshops and everything. Get the full range of experience.
Cultural issues: Most of the participants indicated that cross-cultural issues were dealt with respectfully in the OP and there was a high level of racial tolerance and integration:
- Well, as a Medical Observer I didn’t feel any racial discrimination at all. Yeah, people are generally respectful.
One reason for this was the fact that many of the doctors at the Hospital were also overseas-trained:
- Most of the junior doctors are overseas trained doctors... so I think they’re very good.
Payment: During the three months of their observership, the doctors were not on the payroll. Although certainly not a positive aspect of the program, it is noteworthy that some of the doctors were financially well-supported and so did not consider this a negative aspect. For example:
- No, it [no pay] wasn’t the issue. I think I just felt like doing things without pay. I was happy, I mean, I didn’t mind.
A minority of the participants did point to some negative aspects of the OP experience which they indicated interfered with their learning experience. One participant mentioned problems with being ‘put on the spot’ with questions which led to feelings of being ‘put down’. Another spoke of a negative experience with one of the consultants that involved continual criticism and humiliation. Others spoke of the fact that the support and encouragement offered by doctors depended on the personality of the supervising doctors, with some less responsive and supportive than others.
In comparison to the financially-supported doctors mentioned above, many participants indicated that the lack of income during the OP was a significant negative aspect of the program. For example:
- … find [no pay] very stressful with the family. Then you need to pay a big fee for the medical exams. So they’re very stressful.
Also, additional expenses associated with attending the OP, such as travel costs, added to the hardship. Mention was made that some observers were put on the Hospital roster so that they could obtain some income whilst participating in the program.
Cross-cultural problems: Some of the participants spoke of cross-cultural problems they encountered during the OP experience. These participants reported racial tension at times. For example:
- I think some percentage of people treating us less, second [as second class citizens]. I think we always feel like a second class [citizen] in a hospital… they see us as groups, not individual.
- Ah both, [laughs] [racial tolerance and racial discrimination].
Some participants expressed their belief that IMGs were vulnerable in the hospital system:
- You can’t make any mistakes. It’s only Australian-trained doctors that can make mistakes. But we can’t.
Program outcomes: The participants detailed a range of successful outcomes they had gained from their involvement in the OP.
- increased confidence as a doctor;
- a sound knowledge of basic medications used in local practice;
- knowledge of how the local system works with appropriate paperwork;
- knowledge of who to refer to and how to refer;
- surgical experience;
- refreshment of prior clinical skills;
- opportunity to learn Australian idioms.
Most importantly, for all of those interviewed, the OP experience led directly onto obtaining paid medical employment in the Australian healthcare system. Such work included appointments at the Hospital, appointments at other hospitals and progression to general practice.
As yet, there is virtually no funding for pre-employment assessment, support, training and supervision of IMGs in most hospital posts where IMGs are employed (McGrath, 2004; PMCV, 2002). The findings from the present study indicate that such funding is not only highly desirable but is likely to achieve important positive outcomes.
Overall, findings indicate that the participants were very positive about their experiences with the OP and emphasised the need for such a program. The program was perceived as essential to provide training to ensure IMGs have sufficient knowledge, confidence and competence to integrate into the Australian healthcare system. These findings are consistent with the work of Remennick and Shtarkshall (1997) who documented that one of the important factors in the successful integration of an IMG into a host medical system is the IMG’s ability to maintain a positive self-image as a professional. The OP training was seen as lifting the status of IMGs in the eyes of their Australian colleagues, providing clinical and health systems knowledge and, ultimately, providing the opportunity for these IMGs to enter medical employment in Australia.
Our findings reinforce Canadian research on IMGs that reports that knowledge of the healthcare system is rated as the first and foremost need of IMGs (Zulla et al., 2008). Also, as Curran and associates (2008) report, new IMGs may experience difficulty understanding how medicine is organised in new countries. IMGs not only have to quickly grasp the protocols of the medical practices to which they are attached but must also understand the organisation of state and federal health systems (Pilotto et al., 2007).
The participants outlined a range of factors that they believed contributed to the success of the program, the most important of which is that the OP provided the IMGs with the opportunity to enter the Australian health system as doctors familiar with the system in which they were working. The support of the Hospital team, who were respectful, communicative, approachable and willing to spend time with the IMGs and who provided positive feedback, was noted as a significant strength of the program. As Pilotto and associates (2007) report, clinicians play an important role in the successful integration of IMGs into the Australian medical workforce and the findings from the present study indicate that their role in the OP is crucial.
Hands-on experience in a variety of departments, including opportunities to interview patients on their own and to participate with supervision in a variety of procedures, including surgery, was highly valued. This finding is consistent with New Zealand research that demonstrates that IMGs report a significant increase in their level of comfort in communicating with patients once they are in a clinical setting (Hawken, 2005).
The quality of the supervision provided was deemed high, providing IMGs with the security to practice with close follow-up, able to ask questions in a responsive environment, where supervisors demonstrated trust, respect and patience. Additional educational sessions on a wide range of topics, along with involvement in the grand rounds, weekly team meetings and weekly intern and junior doctor training were seen as important positive factors contributing to the strength of the program.
There was also discussion of the negative aspects of the program, with descriptions provided of emotionally distressing relationships, and reports of variations in the tolerance and communication abilities of individual doctors. Some of the IMGs reported experiencing racial tension at times and believed that IMGs are perceived as second class and more vulnerable in the Australian healthcare system. Although some of the IMGs were sufficiently financially-supported and not concerned about working for three months without pay, there was a group of the IMGs who felt the lack of income was distressing for themselves and their families.
Overall, the findings reveal positive outcomes from the program including: increased confidence as a doctor; a sound knowledge of basic medications used in local practice; knowledge of how the local system works with appropriate paperwork; knowledge of who to refer to and how to refer; surgical experience; refreshment of prior clinical skills; and the opportunity to learn Australian idioms. Most important as an outcome was the end result of medical hospital employment and, for some, progression to general practice. As noted previously, the OP originated in the Department of Medicine but due to the success and acceptance of the program it was subsequently changed to a hospital-wide recruitment.
The findings presented in this article provide insights into a hospital-based educational initiative designed to help integrate IMGs into the Australian healthcare system. Such insights are important, not only because they address a void in the literature, but because they provide practical insight into the need for, the strengths and weaknesses of, and the outcomes of such a program. It is our hope and expectation that such practical knowledge will be useful to other physicians who are concerned about the educational needs of IMGs.
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