Exploring how immigrant international medical graduates successfully manage complex sociocultural challenges





Background: While immigrant international medical graduates (I-IMGs) contribute significantly to the physician workforce in North America, researchers have highlighted the myriad of ways sociocultural challenges can negatively impact their success. Conceptual understanding that unpacks the complex processes of how I-IMGs effectively manage sociocultural challenges is relatively sparse. In addressing this critical knowledge gap, this study explored how I-IMGs successfully manage sociocultural differences as postgraduate residents.

Methods: We interviewed eleven I-IMGs from diverse backgrounds who are in training or recently trained in a distributed multi-site postgraduate medical training program in Canada. We used the lens of sociocultural learning theory to gain insights into the processes of how I-IMGs describe successful management of sociocultural challenges.

Results: The overarching storyline of participants emphasized that their experiences were humbling as they grappled with inner struggles, emotions, and vulnerabilities while embracing the ambiguity of not knowing what was expected of them. The following dominant themes from their narratives encapsulate the salient processes for how I-IMGs conceptualize and successfully manage sociocultural challenges: 1) successfully navigating transitions; 2) resisting or altering elements of prior sociocultural norms while embracing the new; 3) living and being in community and having supportive social networks; 4) risk taking to self-advocate and actively seek help.

Conclusion: Understanding the strengths and positive strategies for how I-IMGs interface with complex sociocultural challenges has application for medical training institutions. Our insights suggest the need for practical, effective, and continuous assistance within I-IMG training programs to better support future trainees dealing with sociocultural challenges.


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Bates J, Andrew R. Untangling the roots of some IMGs' poor academic performance. Acad Med. 2001;76(1):43-46. DOI: https://doi.org/10.1097/00001888-200101000-00012

Bhat M, Ajaz A, Zaman N. Difficulties for international medical graduates working in the NHS. BMJ. 2014;348:g3120. DOI: https://doi.org/10.1136/bmj.g3120

Chen PGC, Curry LA, Bernheim SM, Berg D, Gozu A, Nunez-Smith M. Professional challenges of non-U.S.-born international medical graduates and recommendations for support during residency training. Acad Med. 2011;86(11):1383-1388. https://doi.org/10.1097/ACM.0b013e31823035e1 DOI: https://doi.org/10.1097/ACM.0b013e31823035e1

Fiscella K, Roman-Diaz M, Lue BH, Botelho R, Frankel R. ‘Being a foreigner, I may be punished if I make a small mistake’: assessing transcultural experiences in caring for patients. Fam Pract. 1997;14(2):112–116. DOI: https://doi.org/10.1093/fampra/14.2.112

Hall P, Keely E, Dojeiji S, Byszewski A, Marks M. Communication skills, cultural challenges, and individual support: Challenges of international medical graduates in a Canadian healthcare environment. Med Teach. 2004;26(2):120-125. https://doi.org/10.1080/01421590310001653982 DOI: https://doi.org/10.1080/01421590310001653982

Harris A, Delaney C. International medical graduates in transition. Clin Teach. 2013;10(5):328-332. https://doi.org/10.1111/tct.12021 DOI: https://doi.org/10.1111/tct.12021

Hashim A. Educational challenges faced by international medical graduates in the UK. Adv in Med Ed & Prac. 2017;8:441-445. https://doi.org/10.2147/amep.S126859 DOI: https://doi.org/10.2147/AMEP.S126859

Jha V, Mclean M, Gibbs TJ, Sandars J. Medical professionalism across cultures: A challenge for medicine and medical education. Med Teach. 2015;37(1):74-80. https://doi.org/10.3109/0142159X.2014.920492 DOI: https://doi.org/10.3109/0142159X.2014.920492

Kalra G, Bhugra DK, Shah N. Identifying and addressing stresses in international medical graduates. Acad Psych. 2012;36(4):323-329. Doi.org/10.1176/appi.ap.11040085 DOI: https://doi.org/10.1176/appi.ap.11040085

Klinger C, Ismail F, Marckmann G, Kuehimeyer K. Medical professionalism of foreign-born and foreign trained physicians under close scrutiny: a qualitative study with stakeholders in Germany. PLoS ONE. 2018;13(2): e0193010. https://doi.org/10.1371/journal.pone.0193010 DOI: https://doi.org/10.1371/journal.pone.0193010

McDonnell L, Usherwood T. International medical graduates – Challenges faced in the Australian training program. Aus Fam Phys. 2008;37(6):481-484.

Michalski K, Farhan N, Motschall E, Vach W, Boeker M. Dealing with foreign cultural paradigms: A systematic review on intercultural challenges of international medical graduates. PLoS ONE. 2017;12(7):e0181330. https://doi.org/10.1371/journal.pone.0181330 DOI: https://doi.org/10.1371/journal.pone.0181330

Najeeb U, Wong B, Hollenberg E, Stroud L, Edwards S, Kuper, A. Moving beyond orientations: a multiple case study of the residency experiences of Canadian-born and immigrant international medical graduates. Adv Health Sciences Ed. 2019;24:103-123. https://doi.org/10.1007/s10459-018-9852-z DOI: https://doi.org/10.1007/s10459-018-9852-z

Skjeggestad E, Gerwing J, Gulbrandsen P. Language barriers and professional identity: A qualitative interview study of newly employed international medical doctors and Norwegian colleagues. Pat Educ Counselling. 2017;100:1466-1472. DOI: https://doi.org/10.1016/j.pec.2017.03.007

Triscott JAC, Szafran O, Waugh EH, Torti JM, Barton M. Cultural transition of international medical graduate residents into family practice in Canada. Intern J Med Ed, 2016;7:132-141. https://doi.org/10.5116/ijme.570d.6f2c DOI: https://doi.org/10.5116/ijme.570d.6f2c

Kehoe A, McLachlan J, Metcalf J, Forrest S, Carter M, Illing J. Supporting international medical graduates’ transition to their host‐country: realist synthesis. Med Ed, 2016;50(10):1015-1032. https://doi.org/10.1111/medu.13071 DOI: https://doi.org/10.1111/medu.13071

Lineberry M, Osta A, Barnes M, Tas V, Atchon K, Schwartz A. Educational interventions for international medical graduates: A review and agenda. Med Ed. 2015;49(9):863-879. https://doi.org/10.1111/medu.12766 DOI: https://doi.org/10.1111/medu.12766

Philpott J, Batty H. Learning best together: social constructivism and global partnerships in medical education. Med Ed. 2009;43:923-924. DOI: https://doi.org/10.1111/j.1365-2923.2009.03436.x

Billett S. Learning throughout working life: A relational interdependence between personal and social agency. British J Educ Studies. 2008;56(1):39-58. DOI: https://doi.org/10.1111/j.1467-8527.2007.00394.x

Wenger E. Communities of Practice: Learning, meaning, and identity. Cambridge: Cambridge University Press; 1998. DOI: https://doi.org/10.1017/CBO9780511803932

Bandura A. Behavioral modification through modeling practices. In L. Krasner & L. Ullman (Eds.), Research in behavior modification (pp. 310-340). New York: Holt, Rinehart & Winston;1965

Bandura A. Social learning theory. Englewood Cliffs, NJ: Prentice Hall; 1977

Bandura A. Self-efficacy: The exercise of control. New York: W.H. Freeman; 1997.

Lave J, Wenger E. Situated learning: Legitimate peripheral participation. Cambridge, England: Cambridge University Press; 1991. DOI: https://doi.org/10.1017/CBO9780511815355

Hodges BD, Kuper A. Theory and practice in the design and conduct of graduate medical education. Acad Med. 2012;87(1):25-33. DOI: https://doi.org/10.1097/ACM.0b013e318238e069

Mann KV. Theoretical perspectives in medical education: past experiences and future possibilities. Med Ed. 2011;45:60-68. https://doi:10.1111/j.1365-2923.2010.03757.x DOI: https://doi.org/10.1111/j.1365-2923.2010.03757.x

Vygotsky LS. Mind in society: The development of higher psychological processes. Cambridge, MA: Harvard University Press; 1978.

Bergman E, de Feijter J, Frambach J, et al. AM last page: a guide to research paradigms relevant to medical education. Acad Med. 2012;87(4):545. DOI: https://doi.org/10.1097/ACM.0b013e31824fbc8a

Varpio L, Aschenbrener C, Bates J. Tackling wicked problems: how theories of agency can provide new insights. Med Ed. 2017;51:353-365. https://doi.org10.1111/medu.13160 DOI: https://doi.org/10.1111/medu.13160

Kahlke R, Bates J, Nimmon L. When I say…sociocultural learning theory. Med Ed. 2019;53:117-118. https://doi.org/10.1111/medu.13626 DOI: https://doi.org/10.1111/medu.13626

Sanderson CA. Social Psychology. John Wiley & Sons; 2009.

Varpio L, Paradis E, Uijtdehaage S, Young M. The difference between theory, theoretical framework, and conceptual framework. Acad Med. 2020;95(7):989-994. DOI: https://doi.org/10.1097/ACM.0000000000003075 DOI: https://doi.org/10.1097/ACM.0000000000003075

Creswell JW. Chapter 7: 'Collecting qualitative data'. In Educational research: Planning, conducting, and evaluating quantitative and qualitative research. Boston: Pearson; 2014.

Etikan I, Musa SA, Alkassim RS. Comparison of convenience sampling and purposive sampling. Amer J Theoretical Applied Statistics. 2016;5(1):1-4. DOI: https://doi.org/10.11648/j.ajtas.20160501.11

Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psych. 2006;3(2):77-101. DOI: https://doi.org/10.1191/1478088706qp063oa

Braun V, Clarke V. What can “thematic analysis” offer health and wellbeing researchers? Intern J Qual Studies Health Well-being. 2014;9. DOI: https://doi.org/10.3402/qhw.v9.26152

Varpio L, Ajjawi R, Monrouxe LV, Obrien BC, Rees CE. Shedding the cobra effect: problematizing thematic crystallization, triangulation, saturation and member checking. Med Ed. 2016;51(1): 40-50. DOI: https://doi.org/10.1111/medu.13124

John-Steiner V, Mahn H. Sociocultural approaches to learning and development: a Vygotskian framework. Educa psychol. 1996;31(3-4):191-206. DOI: https://doi.org/10.1080/00461520.1996.9653266

Hennink MM, Kaiser BN, Marconi VC. Code saturation versus meaning saturation: how many interviews are enough?. Qual health res. 2017;27(4):591-608. DOI: https://doi.org/10.1177/1049732316665344

Matsumoto D, Yoo SH. Toward a new generation of cross-cultural research. Perspect psychol sci. 2006;1(3):234-50. DOI: https://doi.org/10.1111/j.1745-6916.2006.00014.x

Yardley S, Westerman M, Bartlett M, Walteon JM, Smith J, Peile E. The do’s, don’t and don’t knows of supporting transition to more independent practice. Perspect Med Ed. 2018;7:8-22. https://doi.org/10.1007/s40037-018-0403-3 DOI: https://doi.org/10.1007/S40037-018-0403-3

Teunissen PW, Westerman M. Opportunity or threat: the ambiguity of the consequences of transitions in medical education. Med Ed. 2011;45(1):51-59. DOI: https://doi.org/10.1111/j.1365-2923.2010.03755.x

Kilminster S, Zukas M, Quinton N, Roberts T. Preparedness is not enough: understanding transitions as critically intensive learning periods. Med Ed. 2011;45:1006-1015. DOI: https://doi.org/10.1111/j.1365-2923.2011.04048.x

Wong A, Lohfeld L. Recertifying as a doctor in Canada: international medical graduates and the journey from entry to adaptation. Med Ed. 2008;42:53-60. DOI: https://doi.org/10.1111/j.1365-2923.2007.02903.x

Tan A, Hawa R, Sockalingan S, Abbey SE. (Dis)Orientation of international medical graduates: an approach to foster teaching, learning, and collaboration (TLC). Acad Psych. 2013;37(2):104-107. DOI: https://doi.org/10.1176/appi.ap.11040074

Jain P, Krieger JL. Moving beyond the language barrier: The communication strategies used by international medical graduates in intercultural medical encounters. Patient Educ Counselling. 2011;84:98-104. https://doi.org/10.1016/j.pec.2010.06.022 DOI: https://doi.org/10.1016/j.pec.2010.06.022

Teunissen PW, Scheele F, Scherpbier A, et al. How residents learn: qualitative evidence for the pivotal role of clinical activities. Med Ed. 2007;41:763-770. https://doi.org/10.1111/j.1365-2923.2007.02778.x DOI: https://doi.org/10.1111/j.1365-2923.2007.02778.x

Teunissen PW, Watling CJ, Schrewe B, et al. Contextual competence: How residents develop competent performance in new settings. Med Ed. 2021;00:1-10. https://doi.org10.1111/medu.14517

Tsuei SHT, Lee DH, Ho C, Regehr G, Nimmon L. Exploring the Construct of Psychological safety in medical education. Acad Med. 2021;94(11S):S28-S35. https://doi.org/10.1097/ACM.0000000000002897 DOI: https://doi.org/10.1097/ACM.0000000000002897




How to Cite

Marthyman A, Nimmon L. Exploring how immigrant international medical graduates successfully manage complex sociocultural challenges. Can. Med. Ed. J [Internet]. 2023 Dec. 30 [cited 2024 Jul. 24];14(6):40-5. Available from: https://journalhosting.ucalgary.ca/index.php/cmej/article/view/76244



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