This study investigated international medical graduates (IMGs), registered between January 1, 2007 and April 14, 2011, at the Access Centre for Internationally Educated Health Professionals in Ontario. By way of logistic regression in a cross-sectional design, it was found that permanent residents who were recent immigrants had lesser chances of being employed full-time at registration (baseline). By way of survival analysis in a cohort design, it was found that younger IMGs who have been in Canada less than 5 years and who have taken the Medical Council of Canada Evaluating Exam (MCCEE) have the greatest chances of securing residency positions in Canada or the US, whereas IMGs from Eastern Europe, South Asia and Africa have lesser chances. It was revealed that registered IMGs are a vulnerable population, and certain groups may be disadvantaged due to underlying characteristics. These groups can be targeted for specific interventions.

This study investigated international medical graduates (IMGs), registered between January 1, 2007 and April 14, 2011, at the Access Centre for Internationally Educated Health Professionals in Ontario. By way of logistic regression in a cross-sectional design, it was found that permanent residents who were recent immigrants had lesser chances of being employed full-time at registration (baseline). By way of survival analysis in a cohort design, it was found that younger IMGs who have been in Canada less than 5 years and who have taken the Medical Council of Canada Evaluating Exam (MCCEE) have the greatest chances of securing residency positions in Canada or the US, whereas IMGs from Eastern Europe, South Asia and Africa have lesser chances. It was revealed that registered IMGs are a vulnerable population, and certain groups may be disadvantaged due to underlying characteristics. These groups can be targeted for specific interventions.

This study investigated international medical graduates (IMGs), registered between January 1, 2007 and April 14, 2011, at the Access Centre for Internationally Educated Health Professionals in Ontario. By way of logistic regression in a cross-sectional design, it was found that permanent residents who were recent immigrants had lesser chances of being employed full-time at registration (baseline). By way of survival analysis in a cohort design, it was found that younger IMGs who have been in Canada less than 5 years and who have taken the Medical Council of Canada Evaluating Exam (MCCEE) have the greatest chances of securing residency positions in Canada or the US, whereas IMGs from Eastern Europe, South Asia and Africa have lesser chances. It was revealed that registered IMGs are a vulnerable population, and certain groups may be disadvantaged due to underlying characteristics. These groups can be targeted for specific interventions.

This study investigated international medical graduates (IMGs), registered between January 1, 2007 and April 14, 2011, at the Access Centre for Internationally Educated Health Professionals in Ontario. By way of logistic regression in a cross-sectional design, it was found that permanent residents who were recent immigrants had lesser chances of being employed full-time at registration (baseline). By way of survival analysis in a cohort design, it was found that younger IMGs who have been in Canada less than 5 years and who have taken the Medical Council of Canada Evaluating Exam (MCCEE) have the greatest chances of securing residency positions in Canada or the US, whereas IMGs from Eastern Europe, South Asia and Africa have lesser chances. It was revealed that registered IMGs are a vulnerable population, and certain groups may be disadvantaged due to underlying characteristics. These groups can be targeted for specific interventions.

Significance. International Medical Graduates (IMGs) comprise 26% of the physician workforce in the United States and 18% of the physician workforce in Iowa. IMGs fill gaps in health professional shortage areas (HPSAs) in the United States and are significant contributors to the medical community. The State Conrad 30 Program allows states to recruit IMGs to HPSAs. Physicians supported under the Conrad 30 Program are obligated to work in HPSAs for three years. Although an important subset of the physician population, little is known about the experiences of Conrad 30 Program participants, or the factors associated with recruiting and retaining this sector of the physician workforce. Purpose. This dissertation described the characteristics and experiences of IMGs practicing in the Iowa Conrad 30 Program, examined retention intention and actual retention of these physicians, and analyzed factors associated with retention of four or more years. Methods. This dissertation utilized a mixed methods approach. Study 1 examined the characteristics of 410 IMGs participating in the Iowa State Conrad 30 Program between 1996 and 2012, using existing data. Logistical regression was used to compare the characteristics of physicians who were retained for four or more years with those who were retained less than four years, controlling for covariates. Study 2 explored the experiences of nine physicians using in-depth qualitative interviews. Inductive content analysis was used to identify themes related to site selection and retention. Study 3 used a physician survey to analyze physician attitudes and subjective norms on 33 practice factors. ANOVA and linear regression was used to analyze the difference in attitudes and subjective norms by physicians’ intent to remain practicing in Iowa long term and actual retention. Results. Study 1: Of 410 physicians, 378 (92%) met the 3-year program obligation to practice at the original practice site and 280 physicians (68%) were retained four or more years. The average length of retention was 6 years and 4 months (SD = 4 years, 1 month). Male physicians had 2.7 greater odds of being retained four or more years than female physicians (95% CI = 1.39, 5.19). Physicians with a region of origin of the Americas had 0.25 lower odds of being retained four or more years compared to physicians with other regions of origin (95% CI = 0.06, 0.98). Marital status, having children at the time of hire, training in the Midwest, practice specialty, and salary were not significantly associated with odds of being retained four or more years. Study 2: Nine physicians completed semi-structured interviews. Themes from the interviews included: Physicians’ visa obligation requirements drove the initial site selection. Physicians had minimal knowledge about the state prior to selecting a practice site and had little intent to remain practicing in Iowa long term when making the initial practice site selection. Visa-related issues and the physician’s perception of mistreatment due to the visa status influenced the retention decision. The practice setting and personal motivators influenced the retention decision through the practice model, community attributes, influence of salient others, career motivators, and a sense of place. Study 3: Fifty-one physicians completed a survey regarding their retention intention when initially selecting the practice site, and their attitudes and subjective norms towards the practice and community. The perception of the beliefs of residency/fellowship faculty (subjective norms) were significant (p = 0.01) for those physicians intending to remain at the practice site for their careers. Attitudes towards the community were significantly more positive (p = 0.03) for physicians intending to remain at the practice site for their careers. Positive subjective norms of significant others (p = 0.02) and residency/fellowship faculty (p = 0.04) were significantly associated with actual retention of four or more years. Positive attitudes towards the practice site and employment factors were significantly associated with longer retention in months (p = 0.02, p = 0.03, respectively). The positive subjective norms of significant others and residency/fellowship faculty were significantly related to longer retention in months (p = 0.0002, p = 0.02). Conclusions: The findings of this study provide important empirical data on the factors influencing site selection and retention of IMGs that participated in the Iowa Conrad 30 Program. The findings suggest a modification may be needed for the existing theoretical model, which was based upon the Theory of Reasoned Action. Improving retention of physicians could help improve quality of care and reduce overall costs for physician practices. Understanding why Conrad 30 Program participants may elect to practice in rural and underserved areas, and the factors influencing retention of physicians in these areas can assist employers, program administrators, and policymakers to aid in improving the retention of International Medical Graduates.

Despite advances in medical technologies, interpersonal communication remains the primary tool physicians use to exchange information, make diagnoses, and treat patients (Cameron & Williams, 1997; Groopman, 2007; Ong, de Haes, Hoos, & Lammes, 1995). In the medical encounter effective communication between physician and patient is essential so that beneficial health and wellbeing outcomes are achieved for patients. Taking a discourse analytic approach, this study examined interactions occurring between international medical graduate (IMG) residents, attending physicians, and patients during the treatment advice phase of the supervised medical encounter. The aim of the study was to examine the co-constructed nature of the delivery and receipt of treatment advice and the ways in which physicians and patients managed interpersonal relations through the negotiated activity. The theoretical framework of pragmatic competence was utilized to underpin the study. Physician-patient interactions served as the primary data source. Medical encounter interactions between five different IMG residents and 31 patients were observed and audio-recorded. Observations and a post-medical encounter survey completed by patients served as secondary data sources. The analysis of the data revealed that this medical speech activity embedded within the medical encounter was realized through the use of a variety of discourse strategies and contributions from multiple participants as they attended to the interpersonal and transactional goals associated with the delivery and receipt of treatment advice. Findings provided insights into how multi-party discourse worked to jointly construct and negotiate treatment recommendations. Findings indicated that IMG residents utilized indirect advice giving strategies. Additionally, both IMG residents and patients utilized interrogatives in various ways to engage actively in the treatment decision-making process. Finally, the data revealed how the participants attended to each other's face needs as they worked to enhance, maintain, or challenge face through the dynamic process of negotiating relationships.

No description available.

Background: Physicians do not always provide appropriate patient care, due in part to inadequacy in their education and training. Performance outcomes, such as individuals' examination scores have been linked to future performance as physicians, accentuating the need for high-quality educational institutions. While the medical school accreditation process in the United States assures a uniform standard of quality, approximately one quarter of physicians in training and in practice in the United States graduated from medical schools located outside of the United States or Canada. These graduates of international medical schools (IMGs) have been more likely than domestically educated doctors to practice primary care and treat underserved and minority populations. An increasing proportion of IMGs who seek to enter post-graduate training programs and subsequent licensure in the United States graduated from medical schools located in the Caribbean. The quality of medical education at some of these schools has been questioned. Accreditation systems are frequently viewed as a way to ensure the quality of medical education, although currently there is limited data linking an educational oversight mechanism to better performance of the graduates. In addition, accreditation systems vary in the methodology, standards, and procedures used to evaluate educational programs. The purpose of the first phase of the present research was to examine medical education accreditation practices around the world, with special focus on the Caribbean region, to determine the association of accreditation of medical schools with student/graduate performance on examinations. The aim of the second phase of this research was to evaluate the quality of a select group of accrediting agencies and the association of quality with student/graduate outcomes. Methods All IMGs seeking to enter graduate training positions in the United States must first be certified by the Educational Commission for Foreign Medical Graduates (ECFMG). In addition to other requirements, ECFMG certification includes passing scores on the United States Medical Licensing Examination (USMLE) Step 1 (basic science), Step 2 Clinical Knowledge (CK), and Step 2 Clinical Skills (CS). In the first phase, all IMGs taking one or more examinations leading to ECFMG certification during the five-year study period (January 1, 2006 through December 31, 2010), and who graduated from, or attended at the time of testing, a school located in a country that met the accreditation inclusion criteria, were included in the study population. First-attempt pass rates for each examination were calculated based on personal variables (gender, years elapsed since graduation at the time the individual took an examination [<3 years versus ≥ years], native language [English versus all others]), and on accreditation status of an individual's medical school. Next, separately for each examination, a generalized estimating equations model was used to investigate the effect of accreditation after controlling for the personal variables. Following the assessment of accreditation on test performance at the global level, the same analyses were conducted separately on the data from students/graduates who attended medical schools located in the Caribbean, and on the data from students/graduates who attended medical school not located in the Caribbean. In the second phase, the quality of a select group of accrediting agencies was evaluated according to the criteria determined by a panel of experts to be the most salient features of an accreditation system. Accreditation systems that used 80% or more of the criteria were given a quality grade of A, and systems using less than 80% of the criteria were given a grade of B. The association between the quality of an accreditation system and student performance, as measured by first-attempt pass rates on USMLE, was investigated in this second phase. The Temple University Office for Human Subject Protections Institutional Review Board determined by expedited review that this study qualified for exemption status. Results As of January 2011, there were 173 countries with medical schools listed in the International Medical Education Directory (IMED), of which 118 met the inclusion criteria. During the study period approximately 67,000 students/graduates took Step 1 for the first time, 55,600 took Step 2 CK, and 58,200 took Step 2 CS. Over one quarter of the test takers graduated from, or were students at, schools located in the Caribbean. For the global population, better performance on Step 1 was associated with the male gender, testing within three years of graduation, non-native English-speaking status, and attending a school located in a country with a system of accreditation. For the Caribbean population on Step 1, results were similar, except native English speakers outperformed non-native English speakers. After controlling for covariates, the odds of passing Step 1 for those from accredited schools were 1.8 times greater for the global group and 4.9 times greater for the Caribbean group as compared to the odds of passing the examination on the first attempt for individuals from nonaccredited schools. In contrast, in the non-Caribbean group accreditation was not associated with examination performance. Increased performance on Step 2 CK for the global group was associated with the female gender, testing within three years of graduation, non-native English-speaking status, and attending a school located in a country with a system of accreditation. For the Caribbean population on Step 2 CK, females, those testing closer to graduation, and native English speakers outperformed their counterparts. After controlling for covariates, the odds of passing Step 2 CK for those from accredited schools were 1.3 times greater for the global group and 2.3 times greater for the Caribbean group as compared to individuals from nonaccredited schools. Accreditation was not associated with examination performance for the non-Caribbean group. For all three groups (global, Caribbean, and non-Caribbean), better performance on Step 2 CS was associated with the female gender, testing within three years of graduation, native English- speaking status, and attending a school located in a country with a system of accreditation. After controlling for covariates, the odds of passing Step 2 CS for those from accredited schools were 1.3 times greater for the global group, 2.4 times greater for the Caribbean group, and 1.1 times greater for the non-Caribbean group compared to individuals from nonaccredited schools. In phase two, the expert panel unanimously agreed on 14 essential standards that should be required by accrediting agencies to ensure the quality of physicians. Of the accreditation systems in 18 countries that were analyzed for inclusion of the criteria, four systems, used in 10 countries, were given a grade of A (included 80% or more of the essential standards), and eight systems, used in eight countries, were given a grade of B (included less than 80% of the essential standards). The IMGs attending medical schools accredited by a system that received a grade of A performed better on Step 1 and Step 2 CS as compared to IMGs attending medical schools that are accredited by a system receiving a grade of B. For Step 2 CK, the results were reversed. Certain essential standards were associated with better performance for all three examinations. Discussion The purpose of this study was to investigate the USMLE performance of graduates of international medical schools who voluntarily seek ECFMG certification based on variables related to the accreditation of their medical education programs. In this study, for the self-selected population who took examinations during the study period, accreditation was associated with better performance in specific regions and for some examinations. Of the three examinations, the existence of a system of accreditation had the strongest association with Step 1 performance for the global and Caribbean groups. Many accreditation criteria are directly related to aspects of the preclinical phase of education. The association between accreditation and Step 2 CS was positive for all three groups of students/graduates, although systems of accreditation may have less direct impact on student performance on clinical examinations as students' experiences in the clinical phase are likely more varied. Of the three groups, the existence of accreditation systems had the greatest associated with examination performance in the Caribbean, an important finding considering the large numbers of IMGs educated in this region seeking ECFMG certification and ultimately treating U.S. patients. The quality of accrediting agencies, as determined by the number of essential elements utilized in the systems, was positively associated with performance for Step 1 and Step 2 CS, but not Step 2 CK. The finding supporting the importance of a high-quality accreditation system on Step 2 CS performance is important due to the purpose of this examination in evaluating a physician's skills in a real world setting. This study lends some support to the value of accreditation. Due to the substantial resources needed to design and implement accreditation processes, these results provide some positive evidence beyond face validity, especially in the Caribbean region, that quality assurance oversight of educational programs is associated with the production of more highly skilled physicians, which in turn should improve the health care of patients in the United States and around the world. / Public Health

Competition for seats in Canadian medical schools has driven many Canadians to seek medical education abroad. Systematic barriers make it necessary for internationally educated physicians (IEPs) hoping to practice in Canada to complete postgraduate residencies. To do so, they must transition into new medical education systems. The transitional experiences of internationally educated physicians are not well understood. This phenomenological qualitative study reveals the perspectives of twenty recent graduates from the University of Manitoba Family Medicine residency program. Canadians Studying Abroad constituted the majority of participants. Participant interviews revealed the presence of clinical practice gaps, created by curricular differences in the timing of graduated clinical responsibility between the Canadian and international medical education systems. Participants also shared their experiences of being singled out (visibility and invisibility), rejected and mistreated. They perceived that IEP residents were assigned low status in resident hierarchies. Their experiences are conceptualized as stigmatization.

Submitted by Cristiane Oliveira (cristiane.oliveira@fgv.br) on 2011-05-23T21:07:12Z No. of bitstreams: 1 71060100678.pdf: 1801115 bytes, checksum: 987b6b7177bf9ad0310228c6a72dced1 (MD5) / Approved for entry into archive by Vera Lúcia Mourão(vera.mourao@fgv.br) on 2011-05-23T21:24:54Z (GMT) No. of bitstreams: 1 71060100678.pdf: 1801115 bytes, checksum: 987b6b7177bf9ad0310228c6a72dced1 (MD5) / Approved for entry into archive by Vera Lúcia Mourão(vera.mourao@fgv.br) on 2011-05-23T21:25:49Z (GMT) No. of bitstreams: 1 71060100678.pdf: 1801115 bytes, checksum: 987b6b7177bf9ad0310228c6a72dced1 (MD5) / Made available in DSpace on 2011-05-23T21:47:17Z (GMT). No. of bitstreams: 1 71060100678.pdf: 1801115 bytes, checksum: 987b6b7177bf9ad0310228c6a72dced1 (MD5) Previous issue date: 2010-02-25 / Migration is inevitable and it can be beneficial if well managed. Medical migration is an opportunity to attract new talents and to increase workforce. The purpose of this study was to evaluate the importance of international medical graduates in Brazil's health workforce. A search of current legislation on the matter was carried out. Using a qualitative methodology information on diploma revalidation was collected from universities and internationally trained doctors working in Brazil. Results showed incipient policy on this issue, influenced by governmental and corporate interests leading to an unequal process. A coordinated approach including the Ministries of Health and Education and Conselho Federal de Medicina, and a comprehensive debate on workforce planning would increase Brazil's competitiveness in international labor market and lower the risk to its population's health. / A migração de pessoas pode ser benéfica quando bem administrada. No caso dos médicos é uma oportunidade de atração de talentos ou de oferta adequada de força de trabalho. Partindo do referencial do médico imigrante, esta tese se propôs estudar a sua importância no Brasil e a sua inserção no mercado de trabalho. Para isso, foi feita pesquisa sobre a legislação correspondente - incluindo as determinações das universidades e do Conselho Federal de Medicina. Foi adotada uma metodologia qualitativa para a coleta de informações sobre revalidação de diplomas nas universidades e foram realizadas entrevistas com médicos graduados no exterior trabalhando no Brasil. Observou-se a incipiência das políticas em relação ao tema, influenciadas por interesses governamentais e corporativos, resultando num processo heterogêneo em relação aos seus objetivos. Sugere-se que a aproximação entre os Ministérios da Educação e da Saúde e o Conselho Federal de Medicina, além de um debate abrangente sobre planejamento de força de trabalho, possam aumentar a competitividade do Brasil na atração de talentos e diminuir o risco à saúde da população atribuível à atuação de médicos cuja competência não tenha sido aferida.