Canadian fellowship experience: the different challenges and emotions faced by an International Medical Graduate and mitigation strategies

Abstract

Acknowledging the mental remodeling that a foreign physician goes through and attempting to mitigate the difficulties of this process is crucial to achieving better outcomes in education and patient care. Canada's Healthcare System offers Clinical Fellowship Programs that allow physicians specialists to obtain advanced expertise in a chosen subspecialty. In a Clinical Fellowship, Canadian Medical Graduates (CMGs) practice alongside International Medical Graduates (IMGs); however, there is evidence that they undergo different challenges in the learning experience. IMGs usually have a higher cognitive load during the adaptation period, which can be due to multiple factors, such as the transition to practice in a foreign country, language, level of supervision, teaching methods applied, feeling disconnected from home, and other competing needs fellows face outside of the clinical context. We propose strategies that may help mitigate the transition to practice process that IMGs undergo when starting a Canadian fellowship, such as Self-Efficacy Encouraging Approach, Thinking Framework Across Cultures, and Social Engagement and Wellbeing.

Introduction

Recently, many professionals in many different areas are pursuing experience abroad to increase their knowledge and professional experience. Likewise, physicians from many countries around the world pursue similar goals. Professional motivation for going abroad includes benefits such as obtaining expertise in a subspecialty, learning another country's medical practices, carrying out research, strengthening an academic career application, creating an international network, and understanding how different healthcare systems work. In parallel, personal growth might come from experiencing different languages, cultures, and ways of life.¹

A clinical fellowship program is subspecialty training after residency. It is designed to help specialists obtain advanced expertise in a chosen subspecialty within their specialty. You must already be a specialist to apply for a fellowship program.

The Canadian medical education system has some peculiar aspects when it comes to its application process. These aspects are particularly attractive to International Medical Graduates (IMG). Unlike a fellowship in the United States, a foreign medical specialization degree may be recognized by the College of Physicians of some Canadian provinces, allowing the applicant to practice temporarily under the supervision of a full-licensed physician in an academic center without performing any Canadian board examination.

Although the main goal of an IMG when applying for a fellowship in Canada is personal and professional growth, this usually comes at the cost of facing multiple challenges in a completely new environment. The fear of the unknown and practicing medicine in a completely different culture and context seem to counterbalance the excitement of moving to a new country.²

Thus, considering that CMGs would not have to face these specific challenges related to moving to a new country, would there be any difference in the learning experience of an IMG compared to a Canadian Medical Graduate (CMG) taking in consideration its unique culture and contextual factors? Assuming there were differences, are there strategies in place that may smooth the transition process for IMGs and help close this gap?

Challenges faced during a fellowship by an IMG in Canada

Starting any kind of educational endeavor can be challenging. The need to quickly adapt and incorporate new skills demands effort, concentration, and mental balance.³ Starting a fellowship program is no different and usually leads to a high cognitive load.^4,5 This can be due to multiple factors, such as the transition to practice in a foreign country, language, level of supervision, teaching methods applied, other competing needs fellows face outside of the clinical context and feeling disconnected from home.

Transition to practice in a different country

While the learning process of a new subspecialty is inevitably challenging for both CMGs and IMGs, IMGs have other competing stressors. Early on, they must quickly understand and adapt to practicing medicine in the Canadian healthcare system. Additionally, the workplace culture and the legal implications of professional practice are much more likely to be significantly different for an IMG than for a CMG coming from a different hospital, city or even province. Adaptation and flexibilization can include having good interpersonal skills, adapting communication patterns to the clinical context, learning cultural behaviors regarding hierarchy and the roles of each individual within the team.

Language

Notwithstanding the aforementioned challenges, practicing medicine in a completely new language can be a major stressor for most IMGs.⁴ Most Canadian institutions require English (or French in Quebec Province) proficiency to enroll in a fellowship program. However, proficiency test results often require minimum scores that do not align with the expectations put on the IMG fellow once they reach the workplace and start clinical practice. IMGs usually consider that the new communication challenges hinder their clinical performance in the initial months of the fellowship.⁴ This has to do with the fact that clinical reasoning, decision making, teamwork and other skills demand a much higher cognitive load, and therefore time, when performed in a second language.⁴

Level of supervision

Transitioning to practice in Canada brings other challenges that relate not directly to clinical knowledge or clinical skills. Physicians are only allowed to enroll in a fellowship program in Canada if they are specialists with an independent license for unsupervised practice in their home country. However, as they enter the Canadian system as fellows, they are forbidden from practicing independently. They usually start with close supervision and slowly progress to more distant supervision by another specialist in the field that holds a Canadian independent license. This change in independence, in itself, is a major stressor. It takes one to have emotional intelligence and a growth mindset to understand that supervised practice allows workplace learning to occur when you are being introduced to a new subspecialty.⁶ This is similar to what would be expected of the apprenticeship model to gain mastery in technical skills.⁷ Nonetheless, the current fellowship model allows for learners to build on technical and non-technical skills in a safe learning environment and ensures that patient safety and optimal clinical care are not jeopardized.

Expertise reversal effect

Additionally, it should be taken into consideration that instructional methods that work well for novice learners might not have the same impact on physicians undergoing fellowship. This concept, called the expertise reversal effect, brings to light how some of these teaching methods that work well for novice learners can have no effect or even have a negative impact on more advanced learners. The redundancy of instructions typical of teaching methods for individuals in their initial training may translate to unnecessary extraneous load in a more senior learner. This scenario can cause an overall increase in cognitive load that can be unnecessarily overwhelming, particularly during the initial transition to practice into the Canadian healthcare system.⁸

Maslow's Hierarchy of Needs and Theory of Motivation

Another framework that can help to understand the challenges faced by IMGs is the Maslow's Hierarchy of Needs and Theory of Motivation.⁹ Applied to IMG fellows, Maslow's model suggests that fellows cannot reach their full potential (self-actualization) without first addressing basic needs. The initial phase that IMGs usually go through is the achievement of physiological needs, such as finding housing. The next level, personal safety, may correlate to IMG fellows' challenges with establishing financial services, supporting their family's adjustment, and securing access to health care. Finally, the third level addresses social needs and a sense of belonging. Fellows commonly experience “disconnection” from peers and the healthcare system due to the new culture and new environment. Even though the internet eases long-distance contact, fellows might experience disconnection from their homeland.^3,10 Some of the factors contributing to homesickness are exposure to a different culture, missing family and friends, inability to visit home due to financial or logistical reasons, and difficulty feeling integrated into the new country.^4,10 Additionally, funding is essential to allow a similar quality of life as experienced in their home country. Not infrequently, IMGs need to consume part of their financial savings to reach a similar quality of life abroad during the fellowship period. It is thought that only after IMGs can successfully address all these levels can they build self-esteem and feel respected in their workplace, which then leads to an overall sense of satisfaction and fulfillment.⁴

Suggested strategies to mitigate adaptation challenges

In this section, we bring forward some strategies that may help to mitigate the transition to practice process that IMGs undergo when starting a Canadian fellowship.

Self-efficacy encouraging approach

The Self-Efficacy Theory, proposed by Bandura,¹¹ defines “self-efficacy” as the concept that encompasses one's belief in their ability to succeed. The theory states that people's judgments of their own ability to manage different situations are central to their actions and observing other individuals in a similar position performing successfully can strengthen beliefs in performing similar tasks.

Activities that enable mirroring other fellows' performances are remarkably relevant to embedding the local culture. Dynamics such as buddy calls, peer mentoring in daily practice and discussion rounds can be effective ways to build psychological safety and attenuate the impact of the challenges faced during the transition to practice in the new environment.¹¹

Thinking framework across cultures

Decoding team members' patterns of behavior and beliefs are essential to communicate effectively and maintain a healthy workplace atmosphere. Clear and respectful communication is one of the most important pillars towards building a safe learning environment and is even more crucial in the context of collaborative teams, such as those encountered in most healthcare clinical situations.

It is important to communicate to the interprofessional team members that the IMG fellow is newly transitioning to practice in Canada. Creating awareness that the fellow is still adapting is crucial to establishing a safe learning environment and a supportive network. Many behaviors or actions can be better accepted or understood if taken into consideration that the IMG fellow has a different cultural background and needs time to learn the workplace culture and acquire cultural competency. To illustrate these nuances in diverse cultural background frameworks, Meyer¹² described spectrums of how people tend to think and perform tasks across cultures. These spectrums are applied to many behavior patterns, from how one culture receives feedback to how one interprets leadership. The relevance to decoding these patterns is to build effective and productive communication. Whenever there is a recognition of fellows' needs, it is essential to translate them into actions.^13,14 Therefore, verbalizing thought processes, using closed-loop communication, and engaging in effective feedback may help close this gap.

Social engagement and wellbeing

Engaging in social activities should be fostered in the workplaces as they act as a burden softener and promoters of inclusiveness and mental health. Some activities may assist in psychological balance in a stressful fellowship environment, such as simple coffee breaks during a workday to celebration encounters, night outs, and neighborhood exploration. Moreover, Canadian institutions are striving to address the mental health needs of healthcare workers. Therefore, some tools have been developed and propagated throughout universities, such as counselling services, wellness apps and websites, active groups, codes for spiritual care (e.g., code lavender) and online mindfulness sessions.¹⁵ Encouraging IMG fellows to access these resources is important since it adds to their own knowledge and experience at home.

Conclusion

The presence of IMGs practicing in Canada as health professionals brings many benefits to society, universities, and learners. However, it is important to understand and acknowledge the challenges that come with it. In this context, empathy from Canadian graduates and faculty is pivotal and supports a healthy learning environment and enriches the educational experience. Therefore, acknowledging the mental remodeling that a foreign physician goes through when starting a fellowship program in Canada and attempting to mitigate the difficulties of this process is crucial to achieving better outcomes in education and patient care. The overarching goal is to tailor a prosperity circle, where good experience leads to high-quality learning and retention of the knowledge and skills learned which ultimately brings more interested healthcare learners to the programs. Everyone benefits from a simple human and sensitive gesture such as empathy.

Conflicts of Interest

None declared.

Funding

No external funding sources.

Authors' contributions

Elio Belfiore and Filipe Nadir Caparica Santos contributed to the conception of the work. The design and draft of the manuscript were contributions of Elio Belfiore. All the authors revised the manuscript critically for important intellectual content, gave final approval of the version to be published and agreed to be accountable for all aspects of the work.