Cynthia Katz|Michelle Barnes|Amanda Osta|Ingrid Walker-Descartes
The Acculturation Toolkit: An Orientation for Pediatric International Medical Graduates Transitioning to the United States Medical System
Icahn School of Medicine at Mount Sinai|Illinois College|Illinois College|SUNY Downstate Medical Center|State University of New York|Maimonides Medical Center
open accessjuly 16 2020the acculturation toolkit orientation pediatric international medical graduates transitioning united states medical system cynthia katz md michelle barnes md amanda osta md ingrid walkerdescartes md mph mba cynthia katz md assistant clinical professor department pediatrics icahn school medicine mount sinai associate residency program director department pediatrics icahn school medicine mount sinai email address email protected michelle barnes md associate professor department pediatrics university illinois college medicine associate residency program director department pediatrics university illinois college medicine amanda osta md associate professor department pediatrics university illinois college medicine residency program director department pediatrics university illinois college medicine ingrid walkerdescartes md mph mba assistant professor department pediatrics state university new york downstate medical center college medicine residency fellowship program director department pediatrics maimonides infants childrens hospital brooklyn httpsdoiorg1015766mep2374826510922 sectionsaboutpdf toolsdownload citations sharefacebooktwitteremail abstract introduction international medical graduates imgs consistently contribute us physician workforce fact 25 practicing pediatricians us imgs highlighting needs img trainees imgs face unique challenges acculturation compared peers due unfamiliarity us medical system especially dynamics around patientcentered care literature supports need formal acculturation curricula methods cohort program directors train pediatric imgs coupled findings literature local themes img focus groups identify topics acculturation curriculum three smallgroup workshops utilized didactics discussion roleplay cover topics related patientcentered care challenging communication patients complex psychosocial histories health literacy pilot modified based feedback enhance generalizability resulting fourmodule curriculum presentations supplemental materials presented results 3year pilot 36 pgy 1 trainees postcurriculum surveys reported 81 10 workshop satisfaction plus increased knowledge skills related patientcentered care communication patients roleplays favorite activity 1year followup survey reported workshops influential satisfaction patient relationships easing transition residency discussion pilot acculturation curriculum addressing needs pediatric img trainees well received participants improved comfort level addressing challenging patientcommunication scenarios pediatric programs train imgs incorporate curriculum aid residents transition clinical practice us educational objectives end foursession module international medical graduate learners able 1demonstrate improved understanding us medical culture2illustrate shift doctorcentered approach one focused patientcentered care3apply tools facilitate communication challenging patient encounters4demonstrate increase confidence communicating patients introduction international medical graduates imgs receive medical degree outside us canada constitute 25 practicing pediatricians us1 imgs also make significant portion workforce graduate medical education us 2018 match residents born outside us graduated medical school outside us nonus imgs constituted 12 matched applicants pediatrics residency programs2 14 matched applicants pediatric fellowships3 imgs enter fellowships prior completing residency training program us making needs trainees pertinent issue fellowship program directors well upon entering training programs imgs face unique acculturation challenges especially physicianpatient communication45 patientcentered medicine68 published work topic focuses two themes 1 understanding imgs specific needs challenges 2 proposing strategies support imgs improvement communication language skills9 areas broad literature search revealed little guidance outlining specific acculturation curriculum introduce instill necessary competencies pediatric training10 date mededportal published two curricula pertaining imgs one addressing internal medicine residents chart documentation skills11 addressing asking difficult questions partial focus imgs12 neither specifically addresses acculturation literature highlights need deliberate acculturation curriculum imgs transition us medical system13 needs img trainees include lack familiarity us medical system adjusting new culture mastering nuances communication specific patient populations1417 prior coming us img residents socialized culture home country upon arrival must adjust new culture us practice medicine us even specifically culture pediatrics13 resulting response acculturation toolkit fourmodule acculturation curriculum serves address unique needs img trainees matched pediatric programs across country acculturation toolkit developed team pediatric program associate program directors imgs us extensive experience training mentoring remediating pediatric imgs utilized themes literature well personal experiences training imgs home vital topics specific imgs purpose resource address unique curricular gap img residents longterm objective improved patient outcomes topics identified curriculum instrumental addressing service gaps health disparities many underserved patient populations18 authors curriculum representative sample program directors training programs across country thus curriculum intended generalizable needs imgs means homogeneous broader acculturation literature demonstrates variability immigrants adapt new cultures based cultural differences countries origin host countries well personal factors19 materials intended allow educator implement facilitate curriculum curriculum standalone portions adapted enhance existing cultural competency curriculum improved communication strategies may useful methods development pilot acculturation toolkit implemented 3 consecutive years community hospitalbased residency program serving multicultural urban underserved patient population standardize delivery content faculty member led workshop 3 years pilot curriculum presented three modules current modified version acculturation toolkit consists four modules preparation dissemination acculturation toolkit group collaborating program directors reviewed materials pilot curriculums three modules add generalizability curriculum topic areas expanded new topics added modifications included 1 deeper dive historical context mistrust medical community 2 section conflict resolution deescalation techniques 3 enhanced roleplays order keep discrete deliverable hourlong workshops modules reconfigured fourmodule version described publication target audience learners categorical pediatric interns pgy 1s within first 3 months residency training us class consisted 12 pgy 1s trained various countries well two three nonimg participants decision made exclude nonimgs participating alongside img colleagues anticipated mutual benefits first exposure curriculum would help facilitate nonimgs develop better understanding unique challenges faced img colleagues therefore create cohesive sympathetic learning environment trainees second including pgy 1s would allow sharing perspectives support productive dialogue ideally facilitators experience medical education smallgroup facilitation given support provided facilitators guide appendix instructors notes within presentations facilitators need experience working residents imgs sensitive challenges imgs appendix includes suggested background reading facilitators new working imgs implementation highly recommended acculturation toolkit initiated first 2 months completed within first 6 months academic year experience early participation served balance newness clinical exposure familiarity clinical experience part trainees yet acquired substantial practice experience preworkshop practice experience gave trainees context reflection exercises facilitated rich discussion using experiences attendees twelve pgy 1s divided two groups six participated three workshops ease scheduling groups shuffled workshops six pgy 1s participate workshops together facilitators found groups six worked well candid discussions general recommendation smallgroup work 10 trainees group order enhance cohesive group dynamics discussion prior workshop facilitator sent trainees set reflection questions appendix b order allow trainees formulate thoughts enhance discussion flow workshop ran approximately 60 minutes workshops run sequential order could rearranged needed week prior workshop facilitators asked participants submit clinical scenarios may incorporated workshop discussion preparation workshop facilitators reviewed speaker notes within powerpoint plan discussion points made copies roleplay scenarios separated three roles reserved room space tested computerprojector setup room workshop occurred lunch hour planned food provision advised participants bring food beverages workshop used combination didactics selfreflection pairshare smallgroup facilitated discussion casebased roleplay order provide sufficient content keeping participants engaged throughout workshop 1 overview appendix c focused participants sharing background experiences introduced concept patientcentered care presented historical context mistrust medical profession certain groups using mixture didactic small largegroup discussions easel used throughout workshop write notes used review workshop 1 material workshop 2 following workshop learners completed evaluation form appendix workshop 2 essentials physicianpatient communication appendix e focused challenging patient scenarios conflict deescalation strategies following largegroup discussion learners broke groups three complete 15minute roleplay activity appendix f two roleplay scenarios vaccine refusal parents frustrated wait time clinic scenario three roles doctor parent observer broke learners small groups three groups review scenario roles rotated every 5 minutes participant served three roles scenario small groups reported larger group prior leaving session learners completed workshop 2 evaluation form appendix g workshop 3 importance psychosocial history appendix h covered psychosocial history using combination didactic largegroup thinkpairshare smallgroup roleplay modalities three roleplay scenarios appendix poorly controlled asthma multiple missed appointments obese adolescent scenario included doctor parent observer roles following debrief roleplay trainees completed workshop 3 evaluation appendix j workshop 4 health literacy appendix k defined discussed health literacy teachback method following discussionbased didactic two concepts participants broke smallgroups review roleplay cases roleplay scenarios appendix l 5yearold otitis media 9monthold eczema 14dayold fever scenario included doctor parent observer roles following debrief roleplay trainees completed workshop 4 evaluation appendix assessment evaluations last 10 minutes workshop participants asked complete evaluations containing quantitative qualitative elements assess utility content presented satisfaction workshop structure elicit feedback apply future workshops appendices g j k quantitative data workshop evaluation forms pooled 3 years data assessed mean satisfaction ratings satisfaction time allotted opportunity talk ratings utility toward future patient interactions qualitative data analyzed themes inform adaptations curriculum year year participants asked complete patientpractitioner orientation scale ppos20 administration workshop series validated tool assessing beliefs patientcenteredness ppos used permission author creator literature supports idea medical practice outside us less focused patientcentered care focused doctorcentered care patientcentered care significant theme threaded acculturation toolkit ppos chosen assess impact workshops trainees perception roles giving receiving medical care physician patient respectively ppos scores pooled 3 years implementation analyzed using wilcoxon signed rank test assess change completion three workshops participants also surveyed appendix n via surveymonkey 1 year completion workshop participation assess sustained impact curriculum results thirtysix pgy 1 trainees 12 per academic year participated threeworkshop version curriculum included pilot acculturation curriculum 3 years implementation participants represented 14 different countries medical training listed table participants completed pre postppos well four postworkshop evaluations ppos scores revealed statistically significant postcurriculum increase importance patientcentered care w 10 p 048 mean satisfaction ratings three workshops 10point likert scale 1 worst ever 10 best ever 84 75 85 right opportunity talk common sentiment expressed ratings workshop component extremely helpful 1 helpful 2 5point likert scale 1 extremely helpful 5 extremely helpful future patient interactions participants anticipated applying workshop content challenging communication scenarios patients addressing challenges communication patients different cultures aiming patientcentered care roleplay exercises reported favorite component described useful tools application clinical care table number participants per cohort country trainingtable number participants per cohort country training 1year followup survey 58 completion rate residents reported retained knowledge skills areas improved understanding patientcentered care patient communication skills encounters challenging patients 100 respondents assessed curriculum extremely 1 moderately 2 influential 5point likert scale 1 extremely influential 5 influential improving understanding us medical culture increasing confidence communicating patients making easier transition residency qualitative responses 1year followup surveys fell three themes improved understanding patientcentered care know ok say dont knowi use teach backi make sure identify presenti ask social conditions moreapproach every patient respectpatient communication try better understand patients parentsi try use prejudgmentsi try understand patients socioeconomic statusnow give time parents concerns make understand best possibleskills encounters challenging patientsthe scenario last session helpful two experiences patients happy waiting timei tactfully handle angry parent discussion development acculturation toolkit collaborating program directors identified gap preparation trainees received preresidency training outside us themes presented curriculum successfully addressed areas need imgs availing curriculum generalizable flexible facilitator adapt original content address needs might unique training site populations served individual programs differ cultural identity trainees therefore facilitators may need emphasize deemphasize different parts modules maximize effectiveness mitigating challenges communication posed patientprovider differences thus far components curriculum incorporated separate workshop national conference enhance concepts related acculturation imgs additionally several abstracts utilizing various components acculturation toolkit presented national conferences forums acculturation toolkit generated rich discussions complex issues arise training imgs including challenges faced residents faculty well varying approaches considered address acculturation issues received numerous requests educators program leadership medical trainees levels program coordinators share curriculum materials pleased make acculturation toolkit available programs use support transition img trainees limitations challenges future directions primary limitation study data presented single site reflect threeworkshop pilot version curriculum multisite study therefore intend overgeneralize findings however multiple sites hope successfully inform curriculum translate broad variety learning environments analysis participant feedback original workshops well discussion among acculturation toolkit developed generalizable usable set materials wider range programs curriculum better suited implemented variety programs train broad demographic imgs well program sites serve diverse patient population plan continue implement acculturation toolkit current img trainees program sites intention studying impact curriculum residents interpersonal communication skills patients recognize several limitations relating curricular evaluations first although evaluations completely anonymous six participants group therefore participants may felt anonymous enough completely honest additionally faculty member facilitating workshops one associate residency program directors participants worked closely clinically administratively case faculty member best qualified facilitate workshops however possible trainees would felt vulnerable give negative evaluations would fear retaliation faculty member possibility neutral facilitator explored programs looking eliminate possibility biased evaluations finally assessments used measure satisfaction impact curriculum including pre postppos based selfreported data definition selfreported data introduce bias also using selfreported data assess actual behavioral change rather reports perceived behavior change study osces direct observations patient reports would helpful investigating curricular impact actual behavior change well impact patient care limitation data analyzed img nonimg residents together reflecting way curriculum implemented evaluated described workshops facilitated small groups six evaluations anonymous due small overall sample size even smaller number img residents group ask trainees identify status img nonimg order maintain anonymity prioritized anonymity protect identities participants well facilitate candid evaluations separate data analysis imgs nonimgs could something consider future iterations workshop evaluations particularly increased sample size pilot curriculum local institutional dissemination results acculturation toolkit adapted implemented internal medicine residents anecdotally internal medicine residents also found workshops engaging useful similar mean satisfaction scores pediatric trainees although formal evaluation took place since formal evaluation unable accurately extrapolate whether img trainees subspecialty would benefit subject matter especially pertains familiarity us medical culture patientcentered care communication welcome collaboration nonpediatric colleagues implement curriculum help gather data show benefit img trainees specialties one challenge implementation scheduling optimal time capturing firstyear trainees start busy clinical work may prove challenging another option programs implement fourworkshop curriculum program orientation approach may come set difficulties preworkshop clinical experience may consistent across img participants trainees observership experiences us clinical context discussion trainees us clinical experience therefore lack clinical context trying establish would appropriate implement workshops later additionally uncommon img residents delay starting residency due holdup visa issuance delay could cause img residents miss workshops occur orientation early academic year trainees visabased delays could assigned prework requiring view workshop overview individually thereby contextualizing subsequent tasks contemplate slides outlining specific questions roleplay exercises arriving initiating clinical work trainees could participate facilitated workshops technological webbased learning platforms accommodate distance learning could also consideration address challenges like many programs across us combination nonus foreignborn imgs us imgs american medical graduates varying degrees us clinical experience 3 years implementation pilot acculturation curriculum participants came three categories trainees discussed programs trainees diverse training backgrounds consider trainees participate together curriculum mutual benefit although certain content familiar trainees many curricular topics may novel benefits hearing experiences reflecting perspectives foreignborn colleagues cannot overstated opportunity future evaluation could focus reflections nonimg learners receive content conclusion rigorous needs assessment utilizing focus groups literature review led development acculturation toolkit curriculum supporting materials participant evaluation feedback pilot acculturation curriculum suggest goals met 1year followup demonstrated sustained impact selfreported resident behavior recommend pediatric programs train imgs incorporate acculturation toolkit support imgs cultural nonalignment may pose challenge early stages patient engagement references1 international medical graduates section imgs american medical association website accessed june 13 2018 httpswwwamaassnorgaboutusaboutinternationalmedicalgraduatessectionimgsgoogle scholar2 national resident matching program results data 2018 main residency match national 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