Article Text
Abstract
Objectives International medical graduates (IMGs) who pursue additional training in another country may encounter unique challenges that compromise their learning experience. This paper describes the development of an Online Bridging Program in the Division of Palliative Care at the University Health Network Toronto and examines its effectiveness in improving IMGs’ readiness for Canadian fellowship training.
Methods The annual Online Bridging Program was developed to help new IMGs transitioning to Canadian palliative fellowship using Kern’s framework for curriculum development. Following a needs assessment, eight online modules with weekly live sessions were developed and underwent external content validation and usability tests. After each iteration, the programme was improved based on participant feedback. Evaluation was conducted first through an online survey immediately on completion of the programme and then through qualitative interviews 6 months into the fellowship. The interviews were analysed using Braun and Clarke’s model for thematic analysis.
Results Nine IMGs participated in the Online Bridging Program from 2018 to 2020. All nine participated in the survey and eight in the interviews. Responses to the online survey were almost unanimously positive, suggesting its effectiveness in assisting the IMGs’ transitions into fellowship. The interviews revealed four major themes: the importance of combining online modules and live sessions, reducing the fellows’ anxiety and easing the transition into their new role, an improved overall learning experience and recognising online format limitations.
Conclusion The Online Bridging Program effectively eased IMG palliative medicine fellows’ transition into training and enhanced their learning experience.
- education and training
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Key message
What is already known?
International medical fellows experience signficant challenges when they start new training at different countries which delay thier adaptation and affect their overall training experience.
What are the new findings?
This article describes the development and outcome of the novel Online Bridging Program for new international palliative medicine fellows before they start fellowship training in a different country. The evaulation results indicate that this program was effective in easing the international medical graduates’ transition into their fellowship and enhancing their learning.
What is their significance?
Clinical: there are no direct clinical implications for this program.
Research: orientation programs that consist of online modules andlive video conference sessions may improve international medicalgraduates' transition to a new medcial training in different countries and enhancetheir overall learning experience.
Introduction
The worldwide lack of palliative medicine training programmes is a key barrier to the global advancement of palliative care.1 Fellowship programmes in countries with better-developed palliative care delivery systems may help bridge this gap by offering positions to international medical graduate (IMG) physicians2; however, training in another country presents unique challenges, including communication and language barriers, adjusting to different healthcare organisational structures and practices, different models of teaching and learning, social and cultural differences, and personal struggles related to isolation and financial strain.3–6 These challenges can delay IMGs’ adaptation to their new learning environment and can affect their overall training experience.7
The Division of Palliative Care at the University Health Network (UHN) in Toronto, Canada, in collaboration with the University of Toronto offers comprehensive fellowships of 1 or 2 years in palliative medicine for Canadians and IMGs. Recognising the unique needs of IMGs, we developed the Online Bridging Program to improve their readiness for Canadian fellowship training. This paper describes the development of this programme and evaluates its effectiveness in facilitating IMGs’ transition to a Canadian healthcare environment.
Methods
Curriculum development and implementation
Historically, most orientation programmes were classroom-based and completed prior to commencing training; trainees needed to arrive weeks earlier, accruing additional expenses from taking time off work, and travel and living expenses. Due to the relatively high cost and time commitment, IMGs, especially from low-income and middle-income countries, had limited opportunities to attend these courses.
Given this gap, we conducted two needs assessment focus groups, first with current and former IMG palliative medicine fellows, and then with UHN faculty. All former IMGs described feeling inadequately prepared for their fellowship.
We then designed a curriculum targeting the IMG’s identified needs using Kern’s framework for curriculum development.8 We chose an online format for its global accessibility and flexibility, with two components: (1) asynchronous, self-paced online modules and (2) weekly 2-hour synchronous video conferences moderated by faculty or current IMG fellows.
External content experts (physicians, nurses and ethicists) reviewed and validated each module, and current fellows completed usability tests to evaluate the ease of use of the online resources. The curriculum was modified after each iteration based on feedback, including creating a module on settlement in Canada, and removal of the module on global palliative care. The current list of modules and corresponding learning objectives is provided in online supplemental table S1.
Supplemental material
Programme evaluation
The Online Bridging Program is conducted annually in the 8 weeks immediately before the start of fellowship on 1 July. Since 2018, all incoming IMG palliative medicine fellows were invited to complete the course and to participate in the evaluation study. On each cohort’s completion of the programme, we conducted a two-phase evaluation—a quantitative online survey and qualitative interviews. We then used mixed-method triangulation to determine whether the results corresponded with each other.
Phase 1: online survey
Participants answered an online survey immediately after completing the programme to assess its success in meeting objectives and participants’ self-perceived readiness for the fellowship, using a 5-point Likert-type scale ranging from ‘strongly agree’ to ‘strongly disagree’. Descriptive statistics were calculated for all variables measured. The questions and structure were validated by a survey methods expert.
Phase 2: qualitative interviews
One-on-one interviews of 30–60 min were completed 6 months into the fellowship. One of the authors (HA-M), who is not a member of the division of palliative medicine or the fellowship programme, underwent training to conduct qualitative interviews and facilitated all the interviews privately using a structured guide. The goals of these interviews were to explore the fellows' perceptions of programme efficacy in preparing them for Canadian fellowship training, to assess the impact of the programme on their transition and to identify areas for improvement. We interviewed participants 6 months into their fellowship to allow them sufficient time to implement their new knowledge and skills and to reflect on their transition. All interviews were audio-recorded and professionally transcribed, with identifying data removed. The transcripts were analysed independently by two investigators (Aa-A and MA), guided by Braun and Clarke’s model for descriptive thematic analysis.9 Open coding was applied to identify important concepts, followed by axial coding to organise concepts into themes. Differing perspectives and discrepancies were resolved by discussion between the authors. A member check, where data analysis results are sent back to participants to check for accuracy, was conducted after analysis to validate the results.
Programme evaluation results
Between April 2018 and June 2020, nine IMG fellows completed the Online Bridging Program: 3 in 2018, 4 in 2019 and 2 in 2020.
Phase 1: online survey
All nine IMGs completed the survey. Participants came from nine countries, with varying specialty backgrounds. Online supplemental table S2 details their demographic profile.
Online supplemental figure 1 illustrates participants' responses pertaining to achievement of the course objectives, utility of the online modules and live sessions, easing their transition to fellowship and recommending the programme to other IMGs. All participants agreed that course objectives were met; the online format was easy to use; and the live sessions augmented their learning. While two responded ‘not applicable’ to whether the programme eased their transition into fellowship, six of the remaining seven agreed to this question. All stated they would recommend the programme to their peers.
Supplemental material
Phase 2: qualitative interviews
Eight fellows participated in qualitative interviews. Four major themes emerged and are listed in table 1 with relevant statements from participants. The member check revealed that these themes were consistent with the participants’ views.
Combining online modules and live sessions effectively prepared incoming IMG fellows
Participants noted the importance of both asynchronous and synchronous learning activities, highlighting the need for both modalities within the programme.
Self-paced online modules provided flexibility to IMGs
Most participants were working in their home countries while completing the programme. While some had trouble balancing their full-time jobs with completing the online modules, the majority felt that the flexible nature of the programme provided a good compromise.
Live sessions allowed peer support and mentoring
The live sessions where participants interacted with each other, the facilitators and existing IMG fellows were particularly appreciated. Meeting their future colleagues before the fellowship had a positive impact on their subsequent interactions.
Bridging Program reduced IMGs’ anxiety and eased the transition into their new role
Participants commented on the value of learning what to expect in their training, making them more comfortable to start their fellowship. Some participants stated that they would highly recommend the programme to future IMGs, even suggesting it should be mandatory.
Bridging Program improved the overall fellowship learning experience
Participants greatly appreciated how the Bridging Program introduced the complexities of palliative care practice in Canada. Participants felt that they retained most of their programme knowledge, and this improved overall learning during their fellowship.
Online format has its limitations
Some participants described technical problems with internet-based modules, largely dictated by connectivity and internet speeds. Time differences given the IMGs’ diverse countries of origin caused delays in the live sessions.
Discussion
We have presented the development and preliminary outcomes of the Online Bridging Program, demonstrating how it eased the participating IMGs’ transition into Canadian Palliative Medicine training. Despite the small number of participants to date, the response to the survey was high (100%), and the positive results were complemented by qualitative interviews 6 months after the programme. Participants appreciated the online format, congruent with previous publications that found online orientation programmes for healthcare staff to be effective and sometimes preferable over class-based format for their flexibility, the option to review the material for mastery, and minimising costs of housing and travel.10 11
Ongoing collegial support and mentoring are critical in reducing stress and anxiety among IMGs.12 13 Our live sessions offer immediate access to peers and mentors, similar to traditional classroom environments, creating a virtual community of learners. Participants especially appreciated opportunities to connect with their peers and current fellows during live sessions.
Our findings suggest that the Bridging Program decreased participants’ anxiety about starting their fellowship. Although several studies have discussed the specific needs of IMGs and provided recommendations for orientation programmes,12 13 further studies, like ours, are needed to document their effectiveness in facilitating the transition of IMGs to their new roles.
Despite inevitable technical problems with this platform,14 online learning experiences have been well-received in health professions programmes, especially during the COVID-19 pandemic.15 16 This format may emerge as a preferred alternative to traditional classroom-based orientation.
Strengths and limitations
To our knowledge, this paper is the first to describe the development and evaluation of an online orientation programme for IMG fellows, demonstrating its ability to help IMGs transition into palliative medicine fellowship.
Some important limitations of this paper include the small sample size and the lack of comparison to the experience of IMGs prior to implementation of the programme. We opted not to do a one-group pretest–post-test, recognising the limitations of such a design in demonstrating internal and external validity.
Conclusion
IMGs face unique challenges when transitioning into a Canadian training programme. We have presented the development of the novel Online Bridging Program for IMG fellows in palliative medicine. It has been well received over three iterations, was feasible despite running prior to the start of the fellowship, and demonstrated strong success in easing IMGs’ transition into training and enhancing their learning experience during the fellowship.
Acknowledgments
The authors thank Dr Joyce Nyhof-Young, Dr Risa Bordman and the faculty and fellows who contributed their time and expertise in creating, guiding and facilitating the Online Bridging Program, and also the Palliative Medicine IMG fellows who participated in this study.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Twitter @ahmed_al_awamer
HA-M and MA contributed equally.
Contributors Aa-A, BH, CZ and EK developed and facilitated the programme curriculum. HA-M conducted the interviews in the qualitative evaluation of the programme. MA and Aa-A cleaned and analysed the quantitative data, and performed the thematic analysis. All authors discussed the results. MA, Aa-A and HA-M drafted the manuscript with input from all the authors. Aa-A is the guarantor.
Funding This project was supported by the ‘Art of Possible’ Education Scholarship Grant (2018), Department of Family and Community Medicine, the University of Toronto.
Competing interests None declared.
Patient consent for publication Not required.
Ethics approval This project was completed following approval from the University Health Network Research Ethics Board (18–6061).
Provenance and peer review Not commissioned; externally peer reviewed.