In spite of the pre-residency assessment tools used in Quebec, including the assessment of medical knowledge and clinical skills, a substantial number of IMGs accepted into residency training have difficulty completing their programs and passing the Certification Examination in Family Medicine. Data from the Conférence des recteurs et des principaux des universités du Québec, available on the CMQ website, indicate that at least 10% of IMG residents leave their family medicine residency programs without completing them, and that 55% require additional training.9
One hypothesis, which Bates and Andrew proposed in 2001, is that unsuccessful IMGs have been unable to integrate into the Canadian health system.10
The authors discuss the challenges that IMGs face when they enter the North American postgraduate educational system: difficulties with English; differences in medical education; length of time since medical school graduation and clinical experience; financial and family obligations; traumatic experiences; and different cultural beliefs about gender roles, communication, and similar issues.10
In that article and another on the 7-year experience of the program to assess IMGs in British Columbia,11
they therefore recommend strategies such as an evaluation process that assesses attitudes and behaviour, clear articulation of the program’s expectations and North American expectations for physicians, and experienced faculty who can explore the root causes of academic problems.10,11
The IMGs in our study, however, had had some time to adapt to the Canadian system, although transitioning from one professional and personal culture to another is, of course, an ongoing, long-term process. Our IMGs passed the screening competency examinations leading to recognition of the equivalency of their diplomas, and they spent at least 24 months in a Canadian family medicine residency program. In addition, since 2004, the 4 Quebec family medicine programs have organized a pre–family medicine residency orientation program for IMGs to help them integrate into the Canadian health care system and prepare for their residencies. During residency, family medicine tutors and clinical preceptors devote additional time to helping these physicians integrate and acquire the competencies needed for independent practice.
Clinical decision making
We offer some other tentative explanations. Possibly the poorer performance is not attributable to a lack of medical knowledge and competency in clinical skills, but rather to how and when an IMG learns to translate the knowledge and integrate it with clinical decision making—an ability that CMGs acquire during their clerkships, if not earlier in their training. Recently, Palés et al surveyed medical graduates in Spain about their acquisition of learning outcomes.12
Eleven domains were examined. Students reported that they felt competent in 8 domains—clinical skills, practical procedures, patient investigation, health promotion, communication skills, attitudes and ethical and legal responsibilities, role of the doctor, and personal development—but only partially competent in 3 domains: patient management, medical information search skills, and decision-making skills and clinical reasoning and judgment.12
On the other hand, data from an ongoing study by Brailovsky and MacLellan suggest that IMGs who return to medical school, usually at a clerkship level, complete their family medicine residency and Certification examinations in a fashion comparable to that of CMGs.
Varied educational backgrounds
Another hypothesis is that, unlike CMGs’ accredited, homogeneous medical education, IMGs’ undergraduate medical education is variable, and they are a diverse group. For some IMGs, therefore, the educational process might not provide the foundation in knowledge, skills, and attitudes they need to succeed in Canadian residency training and Certification examinations. For example, van Zanten and Boulet’s recent study revealed considerable variability in undergraduate medical education and performance on the United States Medical Licensing Examination among students from medical schools in different Caribbean nations.13
This variability was evident on the 3 examination components (basic science, clinical knowledge, and clinical skills and clinical skills assessment), although, interestingly, the pass rates were generally higher for the clinical skills component.
The main limitation of our study is a lack of specific information on which IMGs succeed in passing examinations. The study also did not reveal predictors of success. However, the preliminary finding that fewer IMGs than CMGs pass examinations of clinical skills will guide our future research on improving IMGs’ examination performance and ensuring their successful entry into practice.
In Quebec, IMGs have a much lower success rate on the Certification Examination in Family Medicine than CMGs do. This is the case even though the IMGs have passed several screening competency examinations and have successfully completed a 2-year accredited family medicine residency program.
Many questions remain about the reasons for family medicine IMGs’ lack of success on examinations. A clearer understanding of which IMGs are more likely to fail or pass might be achieved by exploring differences between candidates who grew up in Canada but attended international medical schools and candidates raised in different nations. In addition, a closer look could be taken at whether candidates’ performance differs depending on whether or not they attended medical schools in nations where accreditation criteria are similar to those used by American and Canadian medical schools.14
Currently, we are conducting a retrospective analysis of several variables in the 2000 to 2007 files of IMGs who requested that the CMQ recognize the equivalency of their medical diplomas. Data concerning IMGs who complete Quebec clerkships are also being analyzed. One goal of this new study is to explore why many IMGs who pass the pre-residency screening examinations fail the post-residency Certification examination. Another goal is to identify factors that can help IMGs complete their residency training successfully, pass their Certification examinations, and enter family practice in Quebec.