Knowing me, knowing you: evaluation of the impact of trainer involvement at an enhanced induction programme for International Medical Graduates (IMGs)

ABSTRACT

Addressing differential attainment between International Medical Graduates (IMGs) and their peers who hold UK Primary Medical Qualifications remains one of the most significant challenges facing postgraduate General Practice (GP) training. Enhanced Induction programme, such as the Scottish Trainee Enhanced Programme (STEP), is one tool designed to try and facilitate transition into training and reduce this inequity. The STEP course is attended by both the trainee and their educational supervisor, and aims to lay the foundations of a successful and supportive supervisory relationship. Previous work has evaluated this programme from the perspective of the trainee. Through the use semi-structured interviews, we evaluated the impact and the benefits of the programme from the perspective of the educational supervisors, building on the literature on interventions to support inequity in medical education.

KEYWORDS:

• Differential attainment
• GP training
• International Medical Graduates
• induction
• GP Trainers

Introduction

Understanding and reducing differential attainment remains a key priority in postgraduate GP training. Whether the candidate has a primary medical qualification (PMQ) from the UK or not remains the demographic characteristic linked to the largest difference in candidate performance in all progression requirements [1]. A range of interventions have been developed intending to address this inequity including ‘Enhanced Induction’ which aims to facilitate early identification and support for IMGs. Since 2015, NHS Education for Scotland (NES) have offered the STEP programme (Scottish Trainee Enhanced Programme) to all IMGs commencing GP training in Scotland. The programme is delivered over 2 days within the first 6 weeks of training (see Table 1 for programme details). A key feature of STEP is that the educational supervisor is invited to attend alongside their trainee. This aims to facilitate trainer understanding of common challenges faced by IMGs and to develop their appreciation of their trainee’s individual learning needs. Previous research has highlighted that educators can find training IMGs challenging due to their diverse backgrounds and varied clinical experience [2]. This programme aims to lay the foundations of a supportive trainer–trainee relationship, tailored to individual learning needs, which has been suggested as a key factor in addressing differential attainment [3].

Table 1. STEP timetables for sessions A and B.

TOPIC	CONTENT
Cultural transition	This is an interactive session which covers the concepts of Culture, Cultural Competence Culture Shock and Cultural Dimensions. It allows trainees and trainers to familiarise themselves with the concepts of Equality, Diversity and Inclusion. The small group discussions allow trainees to share their journeys and challenges they might have faced as they transitioned from their host country to the UK. Trainer participation is integral to this session.
Communication skills	Good communication skills are important in life in general and to the doctor-patient interaction in particular. Many complaints arise from a breakdown in this communication. The session explores some of the challenges with language and how we can overcome these to make us better communicators.
Reflection skills	Reflective Practice is a key means of learning and developing professionally for UK doctors but is often quite new to those who have trained overseas. As such, the session attempts to introduce ST delegates to the nature of reflection as a means of learning, which is actually very intuitive; and seeks to provide a simple structure which can be used to carry out reflective practice in a professional medical context. We consider where reflective skills can be applied in General Practice training and in small groups look at this in more depth with reference to a supplied example of a case review from the e-portfolio learning log
Become an active bystander	Have you ever witnessed behaviour at work that made you feel uncomfortable? Did you feel able to deal with it? Did you stay quiet because you didn’t want to stand out or make a fuss? Most of us can remember situations in our past when we wished we had acted or spoken up. A bystander is someone who witnesses an unacceptable behaviour. An active bystander takes action to prevent a situation escalating. By the end of this session participants should have a greater understanding of the ‘bystander effect’, be able to recognise micro-aggressions and feel ready to respond with confidence to disrespectful behaviour.
Culturally sensitive feedback and feedback culture	A review of the purpose of feedback and what makes it effective (or not!). An exploration of why culture is relevant to feedback and how to do ‘multi-cultural feedback’. Some thoughts on how to generate a Feedback Culture.
Unconscious bias	This short session introduces the concept of unconscious bias, the way that our brain makes associations that are outside our conscious awareness. These associations are triggered automatically and can influence our attitudes, behaviours and ability to make judgements. Following a short quiz on first impressions we discuss how we can improve our decision-making by recognising unconscious bias and slowing down our thought processes.
Success factors and tips from literature

Building on a previous evaluation from the trainees’ perspective, this study explored the impact of this programme from the educators’ perspective. In particular, considering:

• the impact on trainers’ relationship with their trainees,

• whether attendance facilitated better understanding of their trainee’s challenges and learning needs,

• whether attendance developed trainers’ skills to support future IMG trainees

Methods

Study design

A qualitative study utilising 1:1 semi-structured interviews was conducted between December 2021 and July 2022. Interviews were conducted by two authors (AG and NG). All trainers attending STEP between February 2021 and February 2022 were invited to take part. Verbal consent was sought from all participants with reimbursement of a sessional payment given made reflecting time from the practice to participate.

Data collection

An interview guide was developed based on professional experience and the published literature (Table 2). These video interviews were conducted using Microsoft Teams™, were audio recorded and transcribed verbatim with full consent from participants. Ten interviews were conducted. The mean interview time was 42 min (range 30m12s-64m20s). All interviewees were UK graduates, with four attending GPSTEP for the first time and six for the second time. Six trainers were female and four males.

Table 2. STEP interview schedule.

STEP Interview schedule
These questions are used as a general outline of the interview. The questions will be modified by the interviewer in real time as the interview progresses, to develop emerging themes. The interviewer may deviate and return to the interview schedule throughout the interview.
Background	Could you tell me a little bit about yourself? (Prompt re: where UG, trained etc)
	Is this your first time supervising an IMG trainee? (Have you attended STEP before?)
	Do you (now or prior to STEP) have any perceptions/apprehensions about supervising IMG trainees?
	Were you aware of any challenges faced by IMG trainees prior to STEP? (If so, what were they?)
	Were there any challenges you were aware of for your IMG trainee prior to the course?
	Has any of the above changed because of attending STEP? (Perceptions/apprehensions/challenges? – please can you clarify how?)
Invitation to the course and expectation	What were your initial feelings when invited to STEP?
	Did you attend the course with your trainee?
	What are your recollections/discussions with the trainee about attending STEP together?
	What did you expect to be covered in STEP if this was your first time?
	After having attended STEP – any after thoughts?
Learning	Can you summarise any key take home messages from the STEP event?
	Just to recap- topics covered during the two sessions were Introduction to STEP and Differential attainment, Culture and Culture shock, Trainee journeys, Reflection skills, Communication and language, Exam preparation, Success factors, Bystander training, Feedback to IMG trainees etc.
	Probe if required on individual sessions.
	Can you clarify further about your individual learning points? (details)
	Did anything at the course surprise you?
	Do you think it was a good idea to attend with your IMG trainee? If so, why?
	How does feedback work between you and your IMG trainee?
	Listening to your trainee’s journey- do you feel better equipped to support their transition into the UK culture and system?
Impact	What impact do you feel STEP had on you? Especially as a Trainer
	Has attendance at STEP changed your perceptions of IMGs and if so in what way?
	Has it changed your relationship with your trainee? Has anything changed?
	Has it changed how you interact with patients?
	Has it changed how you interact with colleagues?
	Has the course changed anything in your wider team?
	Can you describe any concrete steps you took to support your trainee because of attending STEP?
Future work	Do you have any suggestions for changes in STEP?
	Is there anything else we can do to support IMG trainees in Scotland GP training?
	Would you recommend this to other trainers?

Data analysis

Individual transcripts were reviewed for accuracy and corrections made if necessary. The interview transcripts were then anonymised and analysed by AG, after every interview where possible, by open coding of the data. The codes were then tabulated (along with relevant quotes) and categorised to generate themes and sub-themes as part of the inductive thematic analysis process. All codes, themes and sub-themes were discussed and ‘sense checked’ with a second researcher (NG) in the team. Ten interviews were conducted, transcribed and analysed and no further new codes were generated. Key themes were then generated using grounded theory and thematic analysis [4,5].

Results

Seven key themes were generated from the data:

1. Cultural Differences in healthcare organisation

2. Networking and Support

3. Trainer–Trainee Relationship

4. Communication and Feedback

5. Differences in approaches to learning

6. Transitional challenges

7. Cultural Safety

1) Cultural differences in healthcare organisation

Trainers recognised that it was challenging for some trainees commencing training to fully understand how general practice works, particularly if they had not been exposed to this before. Differences noted included referrals, communication styles and utilisation of primary versus secondary care. In comparison to their UK-trained peers, they may need to learn about the gatekeeper role of the UK GP as well as membership of the wider practice team. All trainers highlighted the importance of explaining the remit of the GP, understanding the different approaches to medicine, and focusing on the less medical aspects of training.

Just some cultural differences … using the hospital and how we use the hospital … use of GP is kind of first line and what’s within our remit and what isn’t.

(Trainer 9)

‘I think it is harder for someone starting out in who’s never had any experience of general practice ever to be as slick as someone who’s already done four months in their foundation year and’. [some UK medical schools spend huge amounts of time in general practice]

(Trainer 8)

2) Networking and support

Trainers reflected on the networking opportunities for trainers and trainees that STEP provided. It was an important opportunity for trainees to be aware of each other and highlighted the potential role of peer support.

Knowing that you are not alone and to be able to stay in touch with each other must be so helpful for these trainees.

(Trainer 1)

Trainers spoke of how this also provides an opportunity for trainer peer support, in addition to their usual structures (e.g. trainer groups). They valued resources being highlighted and meeting the Deanery team who they could then contact for future advice.

3) Trainer–trainee relationship

STEP was described by all participants as positively impacting on the trainee–trainer relationship.

I feel it’s allowed me to get the best out of my relationship with my trainee because it’s giving me a good start and hopefully, he feels like I’m on his side as well.

(Trainer 7)

Trainers felt establishing this relationship helped ensure both were on the same page with a shared understanding of the challenges.

The trainee-trainer relationship is quite intense and needs to be a constructive and trusting relationship If it’s going to be productive. STEP goes a long way in facilitating that.

(Trainer 8)

Trainers reflected on having protected time to begin sharing experiences with STEP setting the scene for open communication, e.g. a prior concern had been that trainees might feel their trainer was prying when asking about their background or previous experience.

STEP … allows a conversation and gives a permission to have that difficult conversation.

(Trainer 8)

4) Communication and feedback

Communication and feedback were a common focus for all trainers with two key aspects reported; how the trainees communicated but also the language that trainers use to offer feedback. A common concern was how to help trainees understand cultural variation, accents, and colloquialisms so that they are well understood by the patients.

I suppose we all know the challenges faced by IMGs about language and communication. I now feel I should try and be clearer about my language especially when I am giving feedback.

(Trainer 2)

Trainers discussed written language too, in terms of how trainees reflect in their portfolios and how they respond to feedback. Trainers were largely positive regarding feedback, stating STEP had helped set the tone and developed understanding amongst trainees of the purpose of feedback.

I hope with the relationship we now have they understand it’s constructive criticism and you know that’s what we’re always saying we’re building on this to make them better and more efficient.

(Trainer 9)

Trainers felt they had a better understanding of cultural variation when it comes to feedback, recognising the importance of culturally sensitive feedback, e.g. awareness of a trainee’s background and experience of feedback may inform approach.

Many of them have never had any feedback in their training. We are quite careful here in how we give feedback. They just want to know it plain and simple. Tell me and I will do it sort of thing.

(Trainer 4)

5) Differences in approaches to learning

Most trainers described IMGs as well educated with a wealth of experience and skills, recognising how motivated they must be to have successfully transitioned into a new system. They felt many of the trainees’ struggles were not down to capabilities but due to training in different systems of learning, teaching and assessments.

Lots of challenges in the different ways that they are taught to consult, and the different models of consultation and the different ways that they’re taught in general, very didactic.

(Trainer 4)

The teaching and learning process is so different to what they are used to. It is that deep learning which they struggle with.

(Trainer 10)

Trainers also highlighted a lack of experience in reflective practice as a challenge for some trainees.

They don’t have a clue about reflection. Knowledge is power but it is the application to day-to-day practice that they need to learn. This is quite alien to them.

(Trainer 6)

6) Transitional challenges

IMGs experience significant professional and personal transitional challenges. Trainers reported STEP helping them appreciate some of these challenges and the journeys trainees had been on, which they had previously perhaps not fully recognised. It could also prompt consideration of how these challenges may impact performance, allowing trainers to appreciate and address trainees’ individual and holistic support needs.

The kind of challenges that they’ve had to overcome to get here, I found that really humbling because the stories that people were saying how they’ve worked and what they’ve done and the sacrifices that they’ve made.

(Trainer 9)

There are so many facets from finding a bank account and a house and accommodation which … I hadn’t really thought about. Kind of a bit more social nurturing outside of work I think they need.

(Trainer 5)

7) Cultural safety

One of the key areas that all trainers identified is being an active bystander and challenging unconscious bias from the wider team and patients to help ensure that trainees are well supported. Trainers commented on their understanding of the importance of diversity, inclusion and belonging within their wider team which can support cultural and psychological safety.

Being aware that the importance of stamping something out early and not just watching it and observing it and doing nothing.

(Trainer 5)

I think actually an active bystander session would be a really good session to do with the wider team.

(Trainer 6)

Discussion

While enhanced induction programmes are offered to IMG GP trainees across the UK, the Scottish Trainee Enhanced Programme (STEP) is unique in that it invites the trainer along to the induction day. Our work, building on a previous evaluation from a trainee’s perspective [6], suggests that STEP can offer a platform for trainees and trainers to develop trust and psychological safety, facilitating development of a supportive trainee–trainer relationship.

While the potential positive impact of this relationship was highlighted in the recommendations from the 2019 Work Psychology Group report on Differential Attainment [3], our paper presents an example of how to start to lay the successful foundations of this. This aligns with a previous Dutch study highlighting the importance of the expectations of the trainer and the personal relationship between trainees and trainer in developing a mutually trusting relationship [7].

Many of our findings triangulated those from the earlier evaluation of this programme from the trainee’s perspective [6]. Both studies identified cultural differences, in particular communication styles, and the skill of reflection as areas benefitting from additional attention. Furthermore, trainers felt STEP developed their awareness of resources they can utilise to support their trainees as well as developing their confidence to challenge unconscious bias and to be active bystanders amongst staff and patients to create culturally safe learning environments.

There is no expectation that a single intervention will eliminate differential attainment but this study does demonstrate how STEP can lay the foundations of a supportive trainee–trainer relationship for IMGs. While dialogue and consideration is prompted about the breadth of difficulties which may be encountered, potential preventative measures can be agreed, and trainers can be equipped with resources and contacts to support and guide their trainees through what can be a challenging period.

Strengths and limitations

In contrast to previous research focusing on trainees' perspectives, this study evaluates the impact of this programme on trainers. It is recognised that participants may have been a self-selecting group of motivated individuals. Trainer experience ranged from very experienced to new trainers, so some of the factors identified as difficulties may be reflective of individual trainer journey as opposed to specific involvement with IMGs. There was a geographic spread of participants with a mix of urban and rural trainers.

All interviews were undertaken virtually so the impact on rapport building and technological challenges was considered. As one of the interviewers was a clinical lead for the course, consideration was given to how candid participants might be about their experiences. To mitigate against this, the interviewers emphasised their desire for feedback to develop and improve the course. Utilisation of an interview schedule facilitated exploration of key areas while providing participants time to add anything they felt had not been specifically explored.

Conclusions

This study examined the experience of trainers who had attended a well-established enhanced induction programme for International Medical Graduates commencing GP training in Scotland. It builds on the existing literature through enhancing understanding of the impact of the programme on the educational supervisors’ learning and its role in laying the foundations for a supportive trainee–trainer relationship. As the number of IMGs choosing to enter GP programmes across the UK continues to increase, this work adds to the evidence base for how we can start to support equity in attainment from the start of GP training.

Ethical approval

Under UK ‘Governance arrangements for Research Ethics Committees’, NHS ethical research committee review would not be required for service evaluation. Informed consent was obtained from all participants, and confidentiality was ensured.

Acknowledgments

We would like to thank Tina Huang for her contributions to the early planning stages.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was undertaken as part of NHS Education for Scotland GP Medical Education Fellowship.