Mentorship for the physician recruited from abroad to Canada for rural practice

Abstract

Background: Mentoring is one way to help physicians new to a country assimilate.

Aim: This study examined the feasibility and focus of a mentoring program from the perspective of medical leaders (leaders) and physicians new to Canada (physicians).

Methods: Focus groups with 23 physicians were held in six regional centers. Face-to-face interviews were held with 10 leaders. They were asked to discuss how a mentoring program might be helpful and how a program might be designed and evaluated.

Results: Both leaders and physicians recognized that mentorship would support the physician socially, professionally, and emotionally. They told us that mentorship programs should be structured carefully to build trust, allow mentors and mentees some selection, be in geographic proximity where possible, and have transparent rules. While leaders felt that evaluation would be an important part of a mentorship program, the physicians disagreed noting that it would change the nature of the program. Leaders stated that the ultimate evaluation of the program's success would be found in retention numbers.

Conclusion: Physicians new to a country need support. Mentorship is a feasible approach to support new comers that may result in more efficient and effective integration, enculturation, and higher levels of retention.

Introduction

Mentorship has a long history in many professions. Advocates recommend mentorship for personal development, career guidance, career choice, and research productivity, including publication and grant success (Sambunjak et al. 2006). Benefits to medical mentees include a faster establishment in the new learning and social environment, earlier acquisition of knowledge and skills, a better understanding of the organization, and acquisition of attitudes and behaviors appropriate to the circumstances (Taherian & Shekarchian 2008).

There has been less emphasis on mentorship for practicing clinicians, particularly family physicians and general practitioners. Although, as Gray (1998) notes, mentoring should logically appeal more to general practitioners than to most other groups of doctors due to the inherent complexity of the specialty. No other discipline is based so centrally on the one-to-one consultation with a variety of people and deals with such a wide variety of problems. Indeed, a study in the United Kingdom has demonstrated the utility of mentorship for general practitioners. In that study, mentees described changes they made in practice and the value of the discussions they had with their mentors. Similarly, mentors valued the discussions; they liked the listening, helping and supporting aspects of mentorship. They were most comfortable dealing with professional and educational concerns but expressed discomfort about discussions that focused on personal issues (Freeman 1998).

The need for mentorship for physicians who have immigrated to Canada to enter practice has been identified (Lockyer et al. 2007; Curran et al. 2008). These physicians have described the special challenges of entering practice at both the personal and professional level including the need to understand the health care system; patient expectations; new approaches to referral and investigation procedures; different medications; and the management of chronic diseases, perinatal care, and elderly people (Lockyer et al. 2007; Curran et al. 2008; Klein et al. 2009). One Canadian province has developed a mentoring program for physicians who are recent immigrants to Canada but practicing under the direction of an established family physician. In that province, the mentor provides teaching, supervision, guidance, and regular performance assessment. Both mentors and mentees believe that mentorship is an important way that physician can be integrated into their medical and broader communities (Maudsley 2008).

Many physicians who enter Canada do not stay (Watanabe et al. 2008). For some, this is a part of a career path they have identified to gain training, experience, or income. In other cases, both the immigrant and recruiter hope that the physician will settle indefinitely. Nonetheless, a study of physicians recruited to rural communities in Canada found that staying was conditional on economic, social, and political factors (Klein et al. 2009). A similar study of immigrant physicians in Australia, found that those who most successfully integrated into rural communities were pragmatic about rural life, were involved with the community and its people, valued the opportunities that the community afforded their children and themselves, took an interest in the well-being of colleagues, and had a supportive spouse content to live in a rural community (Han & Humphreys 2006).

Given the reputation that mentorship holds in the literature and practice, this study sought to determine the perspectives of both medical leaders (leaders) and physicians new to Canada working in rural areas (physicians) about the feasibility and focus of a mentorship program.

Table

Practice points

Physicians new to a country require support to effectively meet practice expectations. Mentorship programs are one way to help physicians make the transition more efficiently and effectively. Mentorship programs need to be structured with clearly defined approaches to matching, setting expectations, and evaluation.

Methods

At the time of this study (from May 2007 to February 2008), physicians recruited abroad for practice into Alberta could be given a provisional or “restricted” license by the College of Physicians and Surgeons of Alberta (the regulatory authority) provided they met the requirements of the regulatory authority. This license restricted them to work in a specific community and limited the scope of the services they could provide. These physicians came into the province for a 2-week assessment with a physician in a community in the Region in which they were to work. Following successful completion of the assessment period, the physician would go to another community in the Region to practice. Over a period of 30 months, the physicians were expected to successfully complete Medical Council of Canada examinations to obtain a “full” license. Approximately 50 International medical graduates (IMGs) are recruited annually to meet medical resource needs.

Prior to April 2009, the province was organized into nine Regions; seven rural/regional and two large urban (Calgary and Capital in Edmonton) Regions. The Regions were responsible for the delivery of all health services including public health, mental health, and acute care. Each Region had a Chief Medical Officer, usually a physician, who was responsible for medical services and oversight of the care provided by the physicians.

Perceptions about mentoring were obtained in two ways. Focus groups were held with physicians in six of the seven rural Alberta Health Regions. As Tipping (1998) notes, focus groups can be helpful in determining learning needs either implicitly or explicitly. Unlike interviews, which provide insights from one person; in a focus group, one person's ideas will stimulate other people's conversations. Through group discussion, participants can explore and clarify their views in ways that are less likely during an individual interview in which the participant is stimulated only by the questions posed. In all, six focus groups were conducted by an experienced health care consultant with 23 physicians. The consultant (JK) was aided in all but two of the focus groups by a researcher (JL).

Face-to-face individual interviews were held with the seven medical leaders from the rural Health Regions. Two physicians were employed by the College of Physicians and Surgeons of Alberta (the regulatory authority) and one was chief of medical staff in a community hospital. A total of 10 medical leaders provided data. These leaders were selected because they were responsible for medical services in the facilities served by the physicians. The interviews were conducted by the consultant (JK). An interview format was selected as these leaders were distributed throughout the province and there was no natural forum for a focus group.

In our letter of invitation and at the beginning of the focus groups and interviews, we provided some background information about mentorship and asked both interviewees and focus group participants the following questions:

• How might a mentorship program be helpful to physicians recruited from abroad?

• How might a mentor help a physician new to the province?

• How might a mentorship program be structured?

• How would a mentorship program be evaluated?

The Chief Medical Officers or their designates in six of the seven rural Regions identified physicians on the provisional register for focus groups. Invitations were sent by the consultant (JK). In some cases, the Region Chief Medical Officer also encouraged physicians to participate. The focus groups were held at central sites with larger numbers of IMGs. Full participation was impossible given driving distances, service, and vacation schedules. Focus groups were held in six of the seven rural Regions. A consultant (JK) conducted the focus groups and was assisted in four of these by another member of the team (JL).

The data were analyzed in accordance with the approaches advocated for handling qualitative data (Creswell 2005; Silverman 2005; Corbin & Strauss 2008). All of the interviews and focus group discussions were audio recorded and transcribed. The transcripts were read independently and discussed by two of the authors (JL and HF) who then developed a coding structure of themes and subthemes for the data. The coding structure was applied by the research assistant. Data were again reviewed (by JL and HF) according to the coding structure and discussed to ensure that it was properly coded. Finally, the consultant who collected the data was asked to review an initial draft of the manuscript to verify the interpretation of the data.

The Health Ethics Research Boards of both the University of Calgary and the University of Alberta provided ethics approval for this study.

Results

The 10 medical leaders interviewed included 2 physicians who were employed by the College of Physicians and Surgeons of Alberta, 7 people (6 physicians and 1 administrator) who served as the Vice Presidents, Clinical for the 7 regional/rural health Regions and 1 physician was the Chief of Medical Staff in a remote location that had experienced high levels of turnover. There were two females. There was one specialist, the others were family physicians/general practitioners. All physicians were Canadian medical school graduates.

The 25 physicians included 6 females. Most (17) of the physicians were from South Africa, the remainder were from other parts of Africa (4), Asia (3), and Europe (1). Most of the physicians had been in practice for less than 20 years, 6 graduated between 1980 and 1989, 9 between 1990 and 1999, and 8 after 2000. A graduation date could not be determined for two physicians. There were three physicians in three of the focus groups, four in two focus groups, and eight in one focus group.

There was general agreement by both the leaders and the physicians that a mentoring program would be helpful to physicians new to medical practice in Canada.

Table

Physician	Leader
I would really endorse it. I think that there's a necessity for it and it should have been instituted long ago and I think you’ll have wonderful support. (FG-B)	So I think a mentoring program could provide a real opportunity to help bridge some of those gaps not only for the mentee but also for the health region or for colleagues in understanding where the mentee or the international medical graduate may be coming from. (I-8)

The leaders and physicians envisioned the mentor's role to be multifaceted with three basic responsibilities, that of supporting the mentee professionally, socially, and emotionally. Both recognized that the physician needed help to learn how to work effectively and efficiently in a new environment with clinical practices and approaches that were different and often implicit. All recognized the importance of helping the family. Happy families were likely to remain for several years if well integrated into the social life of the community. Personal connections were recognized as being a critical factor in enculturation.

Table

Physician	Leader
Every mentor[ship] will be different depending on their viewpoint…just for a start on how to refer someone or what blood or laboratory tests are available for certain stuff. You know, is it OK just to order a CT scan – in South Africa CT scans are reserved for specific things, there's specific criteria before you can have a CT scan. (FG-C)	I spend a lot of time explaining how the Canadian medical system works, how our referrals work, what the responsibility for a family doctor in this system is because apparently they’re not getting this from anywhere else. (I-10)
But one again should be thinking of more of social type of things – you know getting this person set in a community which will suit their needs as a person. Make sure that the place where they work offer the things which they’re interested in. (FG-E)	I think it's really important to understand that the physicians themselves may like what they’re doing in a specific rural area or in any area but if mom and the kids aren’t happy it's an impossible situation and they won’t stay, that's all there is to it. So it's very important, this social adjustment and family transition side of it. (I-4)

Structure of program

Both leaders and physicians provided useful suggestions to structure mentorship programs. They described a number of attributes that the mentor requires. These included having a mentor who can gain the mentee's trust, someone with experience, insight, good clinical skills, and an understanding of the system. The mentor must be someone who gets along with all of the health care personnel. Mentors need to be committed to the mentorship and enjoy this type of work relationship. The mentor needs to be able to give constructive feedback.

Leaders recommended that mentors be paid to make up for the time the mentors were not seeing their own patients. The physicians were more ambivalent about the need for payment. Some physicians had personal experience being mentors and agreed with the leaders that the mentee should have a voice in picking a mentor. They thought this could be accomplished by having an interview process so expectations could be determined. Both parties felt it would be important to establish the ground rules related to giving and receiving feedback and the mechanisms for terminating a mentorship that was not productive.

Leaders reported that mentoring should be a one-to-one relationship where the process of mentoring is transparent while physicians suggested that group mentorships might also be considered where there would be more than one mentee per mentor.

The need for a structure with timelines to guide the relationship was recognized. Both leaders and physicians believed close proximity was important with mentoring occurring within the same clinic or community. Leaders thought that the frequency of interaction should be fairly extensive at the beginning but would taper off after a year to monthly meetings between mentor and mentee. Physicians also agreed that the contact with the mentor should be frequent.

The perspectives of both physicians and leaders are presented as follows:

Table

	Physician	Leader
Role of mentor	So I think that the guy has to be interested, has to be friendly, has to be somebody like you can ask him 10 questions at a time and you would not feel like you’re a pain in the neck. (FG-A-3)	Number one is you have to have a mentor that's willing to be a mentor. Can’t twist their arm. If it's not a yes I’m willing to do this then I think there's a problem. There has to be an eagerness, there has to be a willingness and there has to be a drive to do it. (I-5)
Payment for mentors	Maybe people would be more motivated when they know that they are getting paid. But yet, truly, I think if it's not on the basis of someone being paid and making it sort of another profession, it would be nice. It would be more relaxing and provide that relaxed and comfortable relationship. (FG-D-3)	There has to be adequate remuneration because ultimately introducing any individual into a practice, a private practice, will result in a reduction [in patient services]. Reduction translates to income loss. (I-2)

Table

	Physician	Leader
Expectations	But my own experience in [country of origin] is that the more you know mentoring comes naturally … There's somebody that can improve things on how do you do this and how do you do that. (FG-D-2)	Have the mentee be involved in choosing the mentor. As close as the mentor is to the same position the mentee is in the better, so that someone who has already went through this before, someone in the same community, someone about the same age – the closer you can get all those different matches the better. But ultimately you may find for a given mentee, he may appreciate someone who is older than him, that's sort of been in the community, some may prefer someone younger and I think to try and make rules here would be extremely difficult because a lot of it is based upon a relationship and trust. (I-6)
Structure	Rules of the road are up front right off the bat – this is what we’re going to do and this is how you’re going to be evaluated. So he knows and make sure he understands full well what he does. The time frames have to be explained explicitly and where does this evaluation go to, who looks at it, who makes the final decision about whether somebody is prepared… So the whole process has to be very transparent and you’ve got to take a long time to explain it to both parties, so they both understand what their roles and responsibilities are. (I-4)	I think that if there is a mentoring program there should be some kind of standardization so its not just what each person feels is important (FG-F-1)
Contact	That's right, proximity. There must be regular contact. Now how often that contact should be, that's difficult to know… whether it should be once a week, once a month, or maybe initial three month period of continual contact. (FG-B-2)	Ideally you’d be all in the same clinic and there would be interactions throughout the day perhaps of some short duration, whatever. But when we get into situations where the IMG is in a solo practice at a distance from others, that's another area where the question about interactions, and the frequency of interactions and how that interaction should or could occur. (I-1)

Role of evaluation in mentor–mentee relationship

Leaders had several suggestions as to evaluating the mentee. Some believed that exit interviews with both mentors and mentees would be sufficient. Others thought that the evaluation of a mentee should come from all those who interacted with him/her, including patients, office staff, and other physicians. Some recommended measuring competence in laboratory utilization, prescription rates, and appropriateness of medication use. They believed evaluations could occur every 6 months.

The physicians were completely against the mentorship program being used as an evaluation process.

Table

Physician

Leader

If someone thinks you are here to be evaluated, it puts pressure on both who is going to be evaluated and the person who will be doing the evaluation…But if it's put in a more relaxed context, your environment… then both parties I think would be more open and you’d be more open to ask things that you think you don’t know or things that you are not aware of. Yet when you are being evaluated, it puts you under pressure. (FG-D-3)

Well I would make sure that the mentoring program is very structured, has specific objectives that need to be achieved for the mentee, they value the process for those objectives. The mentors are engaged and trained appropriately, and they want to do the work. And in order to do proper mentoring…there's always a certain element of education and teaching. (I-2)

Evaluation of the program

Leaders believed that retention was the ultimate evaluation of a mentoring program, although, personal and family satisfaction along with the goals set for the individual mentor–mentee relationship should also be examined. One leader noted: I guess retention might be an issue if it's not too blunt an instrument. You know, people who stayed because there was a mentoring program. The number of people who were mentees who become mentors (I-3).

Conclusion

Medical leaders and new physicians believe mentoring would help newcomers with the emotional, social, and professional aspects of settlement. They noted that mentors could provide important guidance about the aspects of clinical practice and support the mentee through what is a challenging and difficult time. Consistent with thinking about mentorship in other spheres, participants identified that effective mentors must focus on helping mentees obtain resources, opportunities, and advice (Sackett 2001).

As others (Freeman 1998; Straus et al. 2009) have noted and our participants echoed, successful mentorship programs have to be designed carefully. The setting is unique (Lockyer et al. 2007; Klein et al. 2009). The rural communities are small and may only have 2–4 other physicians. It can be 100 km between towns with regional centers 500 km away. The clinical demands are great as the hospitals provide 24 × 7 care and the physicians have to learn about patient, professional, and system expectations (Lockyer et al. 2007). The ways that the people earn their living and spend their leisure time are different (Klein et al. 2009). While not explicitly stated by our participants, we believe that some of these physicians and their families also face unique linguistic and cultural barriers and may experience overt discrimination (Moller et al. 2008).

The interviews and focus group data suggested that a rural mentorship program needs to be tailored differently than one that would be offered to a physician entering postgraduate training (Taherian & Shekarchian 2008), an academic career (Sackett 2001; Sambunjak et al. 2009; Straus et al. 2009), or a surgeon who is learning specialized skills such as minimally invasive surgery (Birch et al. 2007). In these other settings, the mentees are learning skills and roles that others have already learned with fairly defined and recognizable endpoints. In the case of someone entering a new country, there is less known about how to provide a successful mentorship or what good outcomes might include. Mentors, who are also likely to be practitioners in rural settings, are less likely to have served in formal mentorship or teaching roles previously.

Despite the lack of experience designing this type of mentorship, leaders and physicians recognized that structures related to the selection and assignment of mentors and mentees need to be clear and transparent. Contact has to be sufficiently frequent, at least in the first 3 months. Remuneration will be needed as the time commitment could be significant. Both mentors and mentees would need to make special effort to meet regularly, given the geography of the province. Similarly, Freeman (1998) found careful attention was needed to plan a mentorship initiative, define the role of the mentor, recruit mentors and mentees, and select and train mentors.

Leaders and physicians held different perceptions about the role of evaluation and assessment. Leaders felt that evaluation of the mentee was a mentor role. The physicians believed that the mentors should not evaluate them as it would change the relationship. This apparent dichotomy may be anticipated. Mentors have traditionally assumed responsibility for the growth and development of (young) novices or apprentices. In this setting, mentors may be younger than their mentees. The mentor needs to focus on the personal and professional growth of the mentee, but the mentee should not be treated as a novice student needing initial development into the profession of medicine (Freeman 1998). Nonetheless, it will require resolution as the mentorship program is developed. In the mentorship program established in Maritime Canada, the mentees functioned under the auspices and direction of the mentor who assumed responsibility for the care provided, much like a resident (Maudsley 2008). In the Alberta setting, the physicians will be independent practitioners, albeit with a license that is restricted by geography and scope of practice.

Leaders felt the ultimate test of success lay in numbers of physicians retained in rural communities; although, they acknowledged that other measures including satisfaction levels of the mentors and mentees would also provide helpful information, an approach taken in other studies (Freeman 1998; Maudsley 2008).

It is clear that there will be a need to provide continued support for physicians who immigrate. IMGs constitute between 23% and 28% of physicians in the United States, the United Kingdom, Canada, and Australia (Mullan 2005). The design of a mentorship program will determine its success. Finally, the success of mentorship is two sided with responsibility for success held by the actions of both the mentor and mentee. Both individuals must take responsibility to ensure mutual benefit in a relationship that requires time, patience, dedication, and selflessness (Moller et al. 2008).

Acknowledgments

This study was funded through grants received under the auspices of the Integrated Health and Learning Project from Alberta Health and Wellness, Alberta Advanced Education and Technology, University of Alberta, and Ethicon Johnson and Johnson. The purpose of the funding was to conduct a feasibility study for a mentorship program for international medical graduates, preceptors for the rural integrate clinical clerkship program, and surgeons wishing to develop minimally invasive surgical skills. Mentorship related to the IMG was one portion of the study. We particularly thank Lorrie Gallant for transcribing the focus groups and interviews and Monica Chu for coding the data.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.