Conducting an objective structured clinical examination under COVID-restricted conditions.

BACKGROUND: The administration of performance assessments during the coronavirus disease of 2019 (COVID-19) pandemic posed many challenges, especially for examinations employed as part of certification and licensure. The National Assessment Collaboration (NAC) Examination, an Objective Structured Clinical Examination (OSCE), was modified during the pandemic. The purpose of this study was to gather evidence to support the reliability and validity of the modified NAC Examination. METHODS: The modified NAC Examination was delivered to 2,433 candidates in 2020 and 2021. Cronbach's alpha, decision consistency, and accuracy values were calculated. Validity evidence includes comparisons of scores and sub-scores for demographic groups: gender (male vs. female), type of International Medical Graduate (IMG) (Canadians Studying Abroad (CSA) vs. non-CSA), postgraduate training (PGT) (no PGT vs. PGT), and language of examination (English vs. French). Criterion relationships were summarized using correlations within and between the NAC Examination and the Medical Council of Canada Qualifying Examination (MCCQE) Part I scores. RESULTS: Reliability estimates were consistent with other OSCEs similar in length and previous NAC Examination administrations. Both total score and sub-score differences for gender were statistically significant. Total score differences by type of IMG and PGT were not statistically significant, but sub-score differences were statistically significant. Administration language was not statistically significant for either the total scores or sub-scores. Correlations were all statistically significant with some relationships being small or moderate (0.20 to 0.40) or large (> 0.40). CONCLUSIONS: The NAC Examination yields reliable total scores and pass/fail decisions. Expected differences in total scores and sub-scores for defined groups were consistent with previous literature, and internal relationships amongst NAC Examination sub-scores and their external relationships with the MCCQE Part I supported both discriminant and criterion-related validity arguments. Modifications to OSCEs to address health restrictions can be implemented without compromising the overall quality of the assessment. This study outlines some of the validity and reliability analyses for OSCEs that required modifications due to COVID.

International medical learners and their adjustment after returning to their countries of origin: a qualitative study.

INTRODUCTION: International medical trainees, including residents and fellows, must cope with many challenges, such as differences in cultural hierarchical systems, languages, and acceptance. Nonetheless, the need for adjustment perpetuates even after training is completed abroad. When some international trainees return to their countries of origin, they continue to face adjustment challenges due to reverse culture shock. Others must make many further readjustments. This study presents an exploration of the adjustment and coping strategies of international medical learners after returning to their countries of origin upon completion of their programs. METHOD: This study employed a qualitative approach grounded in interpretivism and utilised inductive thematic analysis following Braun and Clarke's method. Semi-structured, in-depth individual interviews were employed to explore the participants' coping strategies. Participants included international medical learners who were (1) international medical graduates who had already returned to their countries of origin, (2) non-Canadian citizens or nonpermanent residents by the start of the programs, and (3) previously enrolled in a residency or fellowship training programme at the University of Toronto, Ontario, Canada. RESULTS: Seventeen participants were included. Three main themes and seven subthemes were created from the analysis and are represented by the Ice Skater Landing Model. According to this model, there are three main forces in coping processes upon returning home: driving, stabilising, and situational forces. The sum and interaction of these forces impact the readjustment process. CONCLUSION: International medical learners who have trained abroad and returned to their countries of origin often struggle with readjustment. An equilibrium between the driving and stabilising forces is crucial for a smooth transition. The findings of this study can help stakeholders better understand coping processes. As healthy coping processes are related to job satisfaction and retention, efforts to support and shorten repatriation adjustment are worthwhile.

International Medical Graduates and the Physician Workforce.

Importance: Physician shortages and the geographic maldistribution of general and specialist physicians impair health care delivery and worsen health inequity in the US. International medical graduates (IMGs) represent a potential solution given their ready supply. Observations: Despite extensive clinical experience, evidence of competence, and willingness to practice in underserved communities, IMGs experience multiple barriers to entry in the US, including the immigration process, the pathways available for certification and licensing, and institutional reluctance to consider non-US-trained candidates. International medical graduates applying to postgraduate training programs compare favorably with US-trained candidates in terms of clinical experience, prior formal postgraduate training, and research, but have higher application withdrawal rates and significantly lower residency and fellowship match rates, a disparity that may be exacerbated by the recent elimination of objective performance metrics, such as the US Medical Licensing Examination Step 1 score. Once legally in the US, IMGs encounter additional obstacles to board eligibility, research funding, and career progression. Conclusions and Relevance: International medical graduates offer a viable and available solution to bridge the domestic physician supply gap, while improving workforce diversity and meaningfully addressing the public health implications of geographic maldistribution of general and specialist physicians, without disrupting existing physician stature and salaries. The US remains unable to integrate IMGs until systematic policy changes at the national level are implemented.

A Bicultural Community-Academic Partnership to Improve the Latina/o Physician Workforce in Washington State (2019-2021).

From July 2019 through April 2021, the Latino Center for Health, a bicultural population health research center at the University of Washington, partnered with community stakeholders to generate evidence to inform elected officials about the need to increase the diversity of the state's physician workforce and ultimately improve Latina/o health in Washington state. Legislative efforts resulted in legislation creating goals for the state's medical schools to admit students representative of the state's population diversity and the creation of a new residency pathway for international medical graduates. (Am J Public Health. 2024;114(S6):S467-S471. https://doi.org/10.2105/AJPH.2024.307627) [Formula: see text].

[Teaching assistants in Argentina have greater intentions to migrate abroad as physicians than other medical students] / Los ayudantes de cátedra en Argentina tienen mayores intenciones de migrar al extranjero como médicos que otros estudiantes de Medicina.

Introduction: The brain drain of physicians from lower-middle-income countries to high-income countries is a growing phenomenon that contributes to global health inequalities. Retention strategies are difficult to implement locally and to specifically target the population at risk of migrating. We hypothesize that medical students who are teaching assistants have greater intentions to migrate to practice Medicine abroad. Methods: Medical students from Argentina were invited to an online survey of 22 multiple-choice questions based on the LIRHUS Network survey, previously used in Latin America. Results: 2,301 medical students were enrolled. Most were young (23 [20-25] years old), single (90%), and female (79%). The majority studied at public universities (87%). The intention to migrate to practice Medicine abroad was more frequent among teaching assistants (36% vs 31%; χ2 = 4.4982; p = 0.0339). After adjusting for sex and age, being a teaching assistant was associated with the intention to migrate to practice Medicine abroad (OR = 1.26; 95% CI 1.02 - 1.55; p = 0.002). Conclusions: Argentine teaching assistants have a greater risk of migrating to practice Medicine abroad. Given their high academic profile, these are valuable human resources trained using the public financing of low-middle-income countries. The loss of these resources could contribute to health inequalities. This is an easily identifiable and accessible subgroup toward which local retention policies could be directed.

Introducción: La fuga de cerebros de médicos de países de ingresos medianos- bajos a países de ingresos altos es un fenómeno creciente que contribuye a las desigualdades mundiales en salud. Las estrategias de retención son difíciles de implementar localmente y de dirigir específicamente a la población en riesgo de migrar. Hipotetizamos que los estudiantes de Medicina que son ayudantes tienen mayores intenciones de migrar para ejercer la Medicina en el extranjero. Métodos: Estudiantes de Medicina de Argentina fueron invitados a una encuesta online de 22 preguntas de opción múltiple basada en la encuesta de la Red LIRHUS, previamente utilizada en América Latina. Resultados: Se enrolaron 2.301 estudiantes de Medicina. La mayoría eran jóvenes (23 [20-25] años), solteras (90%) y mujeres (79%). La mayoría estudiaba en universidades públicas (87%). La intención de migrar para ejercer la Medicina en el extranjero fue más frecuente entre los ayudantes (36% vs 31%; χ2 = 4,4982; p = 0,0339). Después de ajustar por sexo y edad, ser ayudante se asoció con la intención de migrar para ejercer la Medicina (OR = 1,26; IC 95% 1,02 - 1,55; p = 0,002). Conclusiones: Los ayudantes argentinos tienen mayor riesgo de migrar para ejercer la Medicina en el exterior. Dado su alto perfil académico, se trata de recursos humanos valiosos formados con la financiación pública de un país de ingresos medianos-bajos, cuya pérdida puede contribuir a las desigualdades en salud. Es un subgrupo fácilmente identificable y accesible hacia el que se pueden dirigir políticas de retención locales.

Selection of international medical graduates into postgraduate training positions in Canada. Who applies? Who is selected?

Background: International medical graduates (IMGs) are an essential part of the Canadian physician workforce. Considering current pressures on the health care system, an update regarding application numbers and match rates for IMGs to postgraduate positions in Canada is needed. Methods: We conducted a quantitative cross-sectional study to explore the characteristics of IMGs who are currently applying to the Canadian Residency Matching Service (CaRMS) positions to gain a broad understanding of the composition of this group and the factors associated with successful matching. Results: Out of 1,725 applicants in 2019, 14.1% matched on the first attempt and 6.4% after two to three attempts. Only 22.7% matched with a position (57.6% women). Applicants submitted an average 19.6 site/program applications. The percentage of IMGs matched did not statistically differ by gender. The relationship between the year of graduation or geographic area of medical school qualified and matching was significant for the first and second iterations, with current-year graduates and Oceania/Pacific Islands applicants more likely to match. Conclusions: This study provided us with accurate numbers and information about the Canadians studying abroad and IMG groups applying, and factors associated with being matched to the IMG positions through CaRMS, which will be instrumental in informing future selection implications for Canada.

Contexte: Les diplômés hors du Canada et des États-Unis (DHCEU) constituent un élément essentiel de la main-d'œuvre médicale au Canada. Compte tenu des pressions qui s'exercent actuellement sur le système de santé, il est nécessaire de faire le point sur le nombre de candidatures et les taux de jumelage des DHCEU à des postes de résidence au Canada. Méthodes: Nous avons mené une étude quantitative transversale pour explorer les caractéristiques des DHCEU qui postulent actuellement aux postes du Service canadien de jumelage des résidents (CaRMS) afin de mieux comprendre la composition de ce groupe et les facteurs associés à un jumelage réussi. Résultats: Sur 1 725 candidats en 2019, 14,1 % ont été jumelés dès leur première tentative et 6,4 % après 2 ou 3 tentatives. Seulement 22,7 % des candidats ont obtenu un poste (57,6 % de femmes). En moyenne, les candidats ont soumis des demandes à 19,6 endroits/programmes. Le pourcentage de DHCEU jumelés n'était pas statistiquement différent selon le sexe. La relation entre l'année d'obtention du diplôme ou la zone géographique de la faculté de médecine où il avait été obtenu et le jumelage était significative pour le premier et le deuxième tours, les diplômés de l'année en cours et les candidats de l'Océanie/îles du Pacifique étant plus susceptibles d'être jumelés. Conclusions: Cette étude nous a fourni des chiffres et des renseignements précis sur les Canadiens qui étudient à l'étranger et les groupes de DHCEU qui posent leur candidature aux postes destinés aux DHCEU dans le cadre du CaRMS, ainsi que sur les facteurs associés à un jumelage réussi, ce qui contribuera à guider la sélection des futurs candidats au Canada.

An opportunity to be grateful for? Exploring discourses about international medical graduates from India and Pakistan to the UK between 1960 and 1980.

INTRODUCTION: Following India and Pakistan gaining independence from British colonial rule, many doctors from these countries migrated to the UK and supported its fledgling National Health Service (NHS). Although this contribution is now widely celebrated, these doctors often faced hardship and hostility at the time and continue to face discrimination and racism in UK medical education. This study sought to examine discursive framings about Indian and Pakistani International Medical Graduates (IPIMGs) in the early period of their migration to the UK, between 1960 and 1980. METHODS: We assembled a textual archive of publications relating to IPIMGs in the UK during this time period in The BMJ. We employed critical discourse analysis to examine knowledge and power relations in these texts, drawing on postcolonialism through the contrapuntal approach developed by Edward Said. RESULTS: The dominant discourse in this archive was one of opportunity. This included the opportunity for training, which was not available to IPIMGs in an equitable way, the missed opportunity to frame IPIMGs as saviours of the NHS rather than 'cheap labour', and the opportunity these doctors were framed to be held by being in the 'superior' British system, for which they should be grateful. Notably, there was also an opportunity to oppose, as IPIMGs challenged notions of incompetence directed at them. CONCLUSION: As IPIMGs in the UK continue to face discrimination, we shed light on how their cultural positioning has been historically founded and engrained in the imagination of the British medical profession by examining discursive trends to uncover historical tensions and contradictions.

Migration and professional mobility: Rural attraction and retention of South African educated physicians.

Rural communities in Alberta, Canada have faced physician shortages for decades. Attracting internationally educated physicians, including many South African physicians, is one way to address this problem. While much of the research on international medical graduates (IMGs) focuses on the push and pull of attraction and retention, I situate the decision to stay as a matter of geographic and professional mobility, all within a life course perspective. More specifically, I explore physicians' decisions to migrate from South Africa to rural Alberta and the impact of professional mobility on their migrations. To understand the processes, I collected data via semi-structured virtual interviews with 29 South African educated generalist/family physicians with experience in rural Alberta. Research was guided by abductive grounded theory and data was analysed using open thematic coding. I found that South African educated physicians made the decision to leave South Africa and to come to Canada to pursue prestige and opportunity they perceived to be inaccessible in South Africa. However, physicians were limited to perceived low prestige work as rural generalists, while they understood that more prestigious work was reserved for Canadian educated physicians. Physicians who remained in rural communities brought their aspirations to life, or achieved upward professional mobility in rural communities, through focused clinical and administrative opportunities. The decision to leave rural communities was often a matter of lifestyle and burnout over prestige.

Brain drain in pediatric anesthesiology: The geographic and demographic distribution of national origin among pediatric anesthesiologists in the United States.

BACKGROUND: American pediatric anesthesiologists have a long history of international volunteerism. However, the US healthcare system also benefits from the contributions of a large number of physicians who come from other nations to work within its borders. Despite this fact, little is known about the contribution of international medical graduates (IMG) to the pediatric anesthesiology subspecialty. AIMS: To characterize the contribution of IMG to the field of pediatric anesthesiology in the United States, and to elucidate the geographic and demographic distribution of their national origins so as to understand the movement of skilled personnel between countries. METHODS: Online physician directories of American children's hospitals were searched, and anesthesiologists were recorded for their national origin of medical education. International graduates were reported as a percentage of the pediatric anesthesiology workforce. Those attending medical colleges catering to American students ("offshore" medical schools) were analyzed separately from other IMGs. The cohort of non-offshore IMGs were analyzed for national and continental origins, and by national level of economic development. RESULTS: Of 1979 anesthesiologists analyzed, 397 attended medical school outside the United States, with 58 being from offshore schools. The remaining 338 represented 17.1% of the total pediatric anesthesiology workforce. They came from 58 countries on six continents. Of those, 65.1% attended medical school in low- and middle-income countries. CONCLUSIONS: International medical graduates, disproportionately from low- and middle-income countries, compose a large proportion of the US Pediatric Anesthesiology workforce. While these clinicians play a vital role in providing care for American children, the potential impacts of skilled physician loss on their nations of origin must also be considered.

DO seniors and IMGs have lower match probabilities than MD seniors after adjusting for specialty choice and USMLE Step 1 score.

CONTEXT: It is unknown if US residency applicants of different educational backgrounds (US allopathic [MD], Doctor of Osteopathic Medicine [DO], and international medical graduates [IMG]) but comparable academic performance have similar match success. OBJECTIVES: Our objective was to compare match probabilities between applicant types after adjusting for specialty choice and United States Medical Licensing Examination (USMLE) Step 1 scores. METHODS: We performed a secondary analysis of published data in National Resident Matching Program (NRMP) reports from 2016, 2018, 2020, and 2022 for US MD seniors, DO seniors, and IMGs (US citizens and non-US citizens). We examined the 10 specialties with the most available spots in 2022. Average marginal effects from a multiple variable logistic regression model were utilized to estimate each non-MD senior applicant type's probability of matching into their preferred specialty compared to MD seniors adjusting for specialty choice, Step 1 score, and match year. RESULTS: Each non-MD applicant type had a lower adjusted percent difference in matching to their preferred specialty than MD seniors, -7.1 % (95 % confidence interval [CI], -11.3 to -2.9) for DO seniors, -45.6 % (-50.6 to -40.5) for US IMGs, and -56.6 % (-61.5 to -51.6) for non-US IMGs. Similarly, each non-MD applicant type had a lower adjusted percent difference in matching than MD seniors across almost all Step 1 score ranges, except for DO seniors with Step 1 scores <200 (-2.0 % [-9.5 to 5.5]). CONCLUSIONS: After adjusting for specialty choice, Step 1 score, and match year, non-US MD applicants had lower probabilities of matching into their preferred specialties than their US MD colleagues.

Turnover intention of foreign trained physicians in German rehabilitation facilities-a quantitative study.

BACKGROUND: Germany's medical specialist shortage is an acute challenge, especially in the rehabilitation segment. One countermeasure is to recruit foreign trained physicians (FTP), but the high turnover of FTP is a burden on the departments that train them and integrate them professionally. Preliminary research showed that currently one in three physician positions in German Pension Insurance (DRV) contract facilities is filled by FTP.This paper examines factors related to turnover intention of FTP in German rehabilitative departments. METHODOLOGY: In spring 2022, we surveyed FTP across all inpatient and outpatient rehabilitation departments under the German Pension Insurance, using a two-stage cross-sectional approach. We conducted an online survey of FTP and developed a specialized questionnaire that captured sociodemographic, occupation related and professional biographical data, turnover intention, satisfaction, difficulties with professional integration and departmental structural characteristics. To analyze retention within the rehabilitation field, we used a measure of turnover intention, taking into account the direction of potential turnover, residency requirements and considerations of returning to the rehabilitation field. The data was evaluated in a subgroup analysis comparing FTP with and without turnover intention using Fisher's exact tests. RESULTS: The sample includes n = 145 FTP, 119 stating no turnover intention and 27 with turnover intention. More than half of FTP with turnover intention wished to move to an acute care hospital. FTP with turnover intention are comparatively younger and came to Germany and were employed in the rehabilitation departments more recently, indicating an earlier career stage. Besides, career-related and regional factors show the strongest relation to turnover intention. DISCUSSION AND CONCLUSION: The results reveal a group of "established FTP" whose professional integration has been successfully completed. FTP with turnover intention are comparatively younger, career-oriented physicians for whom work in a rehabilitative facility is a career springboard to gain a foothold in acute care clinics. A limitation is that FTP with turnover intention are difficult to reach and may be underrepresented in our sample.

How the training pathways and capacity of rural physicians inform their scope of practice: A qualitative study examining the experiences of Australian and international medical graduates in South-East New South Wales, Australia.

INTRODUCTION: Current strategies to address shortages of rural doctors focus on developing a pipeline for rural generalist practice. Limited research has explored how doctors' professional journey engenders the skills required to practice rurally. OBJECTIVE: This paper analyses how rural general practitioners' clinical pathway informs their scope of practice and future retention. DESIGN: Qualitative thematic analysis using semi-structured telephone interviews. Twenty-one general practitioners appointed in their local health district of Murrumbidgee and Southern New South Wales, Australia, within the past 10 years. Participants comprised 10 Australian medical graduates (AMG) and 11 international medical graduates (IMG). FINDINGS: AMGs and IMGs contrasted how their pathway into rural practice, and capacity to work rurally, informed their scope of practice. Australian medical graduates' familiarity with rural areas was consolidated through congruous experiences, including at rural clinical schools. Paradoxically, the fluency of their training limited the amount of unsupervised experience and confidence AMGs gained. Together with a focus on work-life balance, this limited many to providing mainstream general practice, precluding extending their scope of practice. International medical graduates described disseminated experiences, often unsupervised in high-volume contexts. However, a lack of professional opportunities prevented them from extending their scope of practice. DISCUSSION: IMG and AMG motivation and pathway for working rurally differ. Respective cohorts have concerns regarding requisite skills and knowledge for rural practice, which incorporates opportunity and recognition. Entry points for training should be variable to allow consideration of life stage, prior skill development and extension of scope of practice. CONCLUSION: Doctors' scope of practice is informed by their pathways into rural practice. Australian medical graduates may not gain adequate competence during expedited training programs to confidently undertake extended clinical activities. International medical graduates, however lacked the opportunities and support, to utilise their expertise in rural practice. Complementarily utilising the expertise and commitment of both AMGs and IMGs may synergistically address workforce shortages.

World Psychiatric Association-Asian Journal of Psychiatry Commission on the Mental Health and Wellbeing of International Medical Graduates.

Historically, doctors have migrated for a range of personal, educational, economic, and political reasons. Likewise, medical students from many countries have moved abroad to complete their training and education and may or may not return to their country of origin. Within this context, globalisation has had a major impact on medical education and healthcare workforces, contributing to recent migration trends. Globalisation is a complex phenomenon with positive and negative outcomes. For example, lower-income countries are regularly losing doctors to higher-income areas, thereby exacerbating strains on existing services. Across various national healthcare settings, migrating International Medical Graduates (IMGs) can face socioenvironmental and psychosocial pressures, which can lead to lower mental wellbeing and undermine their contributions to clinical care. Rates of stress and burnout are generally increasing for doctors and medical students. For IMGs, stressors related to migration, acculturation, and adjustment are not dissimilar to other migrants but may carry with them specific nuances. Accordingly, this Commission will explore the history of IMG trends and the challenges faced by IMGs, proposing recommendations and solutions to support their mental health and wellbeing.