Over the last decade, there has been a steady increase in the number of international medical graduates (IMGs) enrolled in North American residency programs. In 2009, IMGs accounted for approximately 24% of all postgraduate Year-1 (PGY1) residents entering psychiatry residency in the United States (1). Moreover, IMGs accounted for 17% of all Canadian PGY1 trainees enrolled in medical and surgical residency training programs in 2008 (2). Within psychiatry, a total of 52 visa trainees were trained in Canadian psychiatry residency programs during the 2008–2009 academic year (2).

Attempts to define IMGs have been discordant throughout the literature as a result of the marked heterogeneity within this group of trainees. The Canadian definition of “an IMG” is a physician who obtained his/her medical degree at a medical school outside of Canada or the United States (3). This definition encompasses three distinct categories of IMGs: 1) Canadians born and raised in Canada who completed their medical training outside of Canada or the U.S. (Canadian IMGs); 2) physicians who are recruited to Canada to meet the needs of Canadian postgraduate training programs or who are sponsored to train in Canada but are expected to return to their sponsoring country at the conclusion of their training (visa IMGs); and 3) individuals who have immigrated to Canada with medical degrees and enter Canadian residency training programs through IMG-specific programs or the second iteration of the Canadian residency matching service (Canadian immigrant IMGs). Therefore, it is clear that the IMGs represent a heterogenous group of trainees that may present challenges to psychiatry training programs in Canada (4).

As a result, several studies have identified specific challenges facing IMGs during their education in North American training programs. Specific challenges facing IMGs have included isolation from family members, language barriers, immigration issues, and a reduction in social status for those trainees who must re-enter psychiatry residency (5–9). IMGs may struggle with their understanding of idioms, nuances, and vernicular terms in everyday communication, which may hinder their performance, especially since North American healthcare settings emphasize collaborative care and interdisciplinary team models (8).

It has been suggested that IMGs in Canadian medical residency programs may transition through phases of loss, disorientation, and adaptation before they eventually feel integrated into their professional environments (10). Similarly, IMGs starting psychiatry residency may experience similar challenges adapting to postgraduate training in Canada and may benefit from preparatory courses and support during this process. In a Canadian survey of IMG trainees and program directors, both groups identified the need for an orientation program addressing differences unique to the Canadian healthcare system (11). A study of IMGs participating in a 1-week, internal-medicine orientation program rated this preparatory program as highly valuable (12). Within psychiatry, the American Psychiatric Association offers a full-day workshop preparing IMGs for their transition into psychiatric practice (13). Despite various pilot orientation programs for IMGs, no published studies have empirically identified the specific needs of psychiatry IMGs.

Using a questionnaire, we sought to determine the needs of IMGs transitioning into five Canadian psychiatry residency programs. Our needs-assessment was used to inform topic areas for an IMG-specific preparatory program to facilitate their adaptation into residency. We hoped that our study could be used to establish key domains to be included in a psychiatry-specific IMG preparatory or orientation program for psychiatry IMGs across Canada.

The study was approved by the University of Toronto Human Research Ethics Board. Psychiatry residency is 5 years in Canada, and the survey sample consisted of all postgraduate Year-2 (PGY2) to PGY5 psychiatry residents at five Canadian psychiatry residency programs: University of Toronto, University of Western Ontario, University of Manitoba, Queens University, and Memorial University. We focused on psychiatry IMGs from these specific programs because of their large number of IMG trainees and varied program sizes.

A total of 43 IMGs between PGY2 and PGY5 were enrolled in the five psychiatry residency programs during the 2008–2009 academic year. The number of potential IMG respondents in each program ranged from 6 to 15. The distribution of residents amongst each training year were as follows: 19 PGY2, 7 PGY3, 8 PGY4, and 9 PGY5 residents. PGY1 psychiatry residents were excluded from the study because of their limited and varied exposure to psychiatry training (2–3 months) in their introductory residency year.

The study questionnaire consisted of 15 questions, divided into sections assessing respondents’ perceived difficulties with transitioning into psychiatry residency as an IMG, respondents’ specific educational needs, and demographic data. The survey content was based on published data on the challenges and needs of IMGs trainees across the fields of medicine (9, 11, 14). Furthermore, we solicited feedback from PGY1 IMG trainees in psychiatry residency at the University of Toronto and educators who had experience with supervising IMG trainees in psychiatry to refine the questionnaire. Last, we piloted the questionnaire in international fellows in psychiatry at the University of Toronto and utilized feedback during this process to further refine the survey instrument. Because of concerns about preserving resident anonymity, we could not include training-level information in the demographic section, as IMG trainees would be identifiable in smaller residency programs.

The final survey questionnaire included a question utilizing a 5-point Likert scale to determine the level of difficulty IMGs faced coping with various areas as they transitioned into psychiatry residency (1: very difficult; 5: very easy). Using a 3-point Likert scale (1: not important; 3: very important), IMG respondents were also asked to rate the importance of 10 different topic areas to be included in a psychiatry residency preparatory course specific to IMGs.

In the spring of 2009, each of the psychiatry postgraduate education offices at the participating universities e-mailed a consent form and a link to a web-based needs-assessment survey. Three reminder e-mails were sent to IMGs in each program over the collection period of 6 weeks.

Data were analyzed with SPSS 17.0 software, and we used descriptive statistics. Furthermore, we hypothesized that the length of time respondents were living in Canada before starting residency and the proportion who spoke English as a first language would influence respondents’ perceived ability to cope with various aspects of transitioning into residency. We converted “time living in Canada” into a dichotomous variable, using time >12 months as the cut-off, given that some IMGs may have completed several months of electives or mandatory pre-residency assessment in Canadian residency programs before starting their residency. We compared time in Canada pre-residency and English-as-a-first-language with respondents’ perceived coping with the transition to residency, using a Mann-Whitney-Wilcoxon test. A p value of <0.05 was considered significant.

A total of 32 psychiatry IMGs completed the web-based questionnaire, yielding a 74% response rate; 41% of respondents were men, and 31% indicated that English was their first language. Respondents completed their medical training in the following regions: Middle East (34%), Asia (22%), Europe (25%), Oceania (3%), and the Americas (16%). Nearly 66% of IMGs were living in Canada for more than 12 months, and 47% had family members living in the city where they were training in psychiatry. Approximately 53% of psychiatry IMGs were members of the national psychiatric association.

Table 1 demonstrates psychiatry IMGs’ perceived difficulties coping with specific areas during their transition into psychiatry residency. During this transition period, respondents reported a high degree of difficulty coping with: gaps in their knowledge of the Canadian healthcare system, gaps in their knowledge of evidence-based medicine/mental health and medical documentation.

Respondents who did not speak English as a first language had significant difficulty coping with language barriers (median scores: 2.5 versus 2; U=37.0; p=0.002) and social isolation (median scores: 3 versus 3.5; U=60.0; p=0.043) during their transition into residency. Respondents who spent ≤12 months in Canada before entering psychiatry residency had greater perceived difficulty coping with gaps in psychotherapy knowledge (median scores: 4 versus 2; U=32.5; p=0.001) and the Canadian healthcare system (median scores: 4 versus 2; U=57.0; p=0.020).

In terms of IMG-specific preparation for psychiatry residency, 88% of respondents felt they received little-or-no preparation for their psychiatry residency from their program, and 69% indicated they would use IMG resources, such as an IMG preparatory course, if they were offered during residency. Approximately 94% of IMGs had no knowledge of IMG-specific preparation courses focused on the transition into psychiatry residency. Furthermore, 63% of psychiatry IMGs felt that faculty in their program should undergo training to assist with IMG transition into psychiatry training programs.

Psychiatry IMGs from the five residency programs perceived all topic areas to be very important to a psychiatry residency preparatory course for psychiatry IMGs (Table 2). Specific topics that IMGs felt were very important to preparatory course included writing consultation and progress notes, taking a sexual history, improving communication skills within a team, and an orientation to the Canadian healthcare system.

To our knowledge, this is the first needs-assessment study examining psychiatry IMG trainees’ perceptions on the challenges and educational needs for IMGs transitioning into psychiatry residency. Our findings support previous literature on IMG-perceived training needs and challenges with a new healthcare system and medical documentation. Also, our needs-assessment suggests that IMGs experienced additional difficulty coping with their gaps in evidence-based medicine or mental health early in their psychiatry residency. Approximately two-thirds of respondents indicated they would use IMG preparatory resources if offered to IMGs transitioning into psychiatry residency. Nearly all listed topic areas were deemed to be important to a psychiatry IMG preparatory course. Therefore, the results indicate a strong preference by IMGs for receiving further preparatory training to facilitate their adaptation to psychiatry residency in Canada.

Our results also highlight the heterogeneity of IMGs in Canada and the need to consider this diversity when designing programs to facilitate IMG adaptation into North American training programs. Respondents who did not speak English as their first language had greater difficulty coping with language barriers and social isolation. Struggles with language may be stigmatizing to some IMGs and can also result in isolation from peers. This underscores the need for mentoring and the development of IMG-specific supports early in residency training. Moreover, when time spent in Canada before residency was considered, our results suggest that IMG trainees who resided in Canada for ≤12 months may have greater difficulty coping with a new healthcare system and gaps in their psychotherapy knowledge. Psychotherapy knowledge gaps may be more challenging to overcome initially because of the need for greater familiarity with the native culture in order to provide a context for fully understanding the patient in psychotherapy. Although cultural-psychiatry training is a mandatory component to Canadian psychiatry training, IMGs may require a longer time in Canada before psychiatry residency to become familiar with boundary-theory and practice in North America (15).

Over 60% of respondents felt that faculty development was necessary in their psychiatry residency programs to facilitate IMG transition into the program. In a survey of practicing physicians in Massachusetts, 62% felt that discrimination against IMGs was a significant issue in their organization (16). Although we did not specifically inquire about discrimination, our survey findings support IMGs’ perceptions that faculty development is necessary to reduce discrimination and facilitate an improved understanding of IMG-specific learning needs and challenges. One resource is the Association of Faculties of Medicine in Canada (AFMC), which offers a six-module faculty development program for teachers of IMGs (3).

Potential limitations of our survey findings should be considered. First, participants were from five select psychiatry residency programs in Canada, which may not be representative of a national IMG sample. Although French is an official language in Canada, we did not have a French-speaking residency program in our study and cannot account for this additional challenge facing IMGs. Also, our study sample was limited to 32 IMG trainees and would have benefited from a comparison non-IMG group. However, the participating residency programs ranged in size and are likely to reflect training issues present in a range of programs both in Canada and the United States. Second, we relied on respondents’ recalling past experiences, and this could have affected respondents’ responses. It would be ideal to prospectively study IMG perceptions early in their training, and longitudinally, to more clearly define the challenges IMGs may encounter over the course of their psychiatry residency training. Furthermore, participants may have responded in a socially desirable manner when asked about specific issues, which could explain why nearly all topics were considered important to an IMG preparation course. The importance of nearly all topics could also be due to lack of specificity in our 3-point Likert scale. Third, our study could have been enhanced by qualitative data to supplement our survey findings and to provide more detailed data on IMG-specific concerns that may not have been captured in the survey. Fourth, our study findings may be limited to Canadian training programs, given the survey sites involved in the study. Finally, our survey only focused on IMG trainees, rather than their supervisors. Given that self-assessment can be problematic, our conclusions would have been strengthened if we had surveyed or interviewed supervisors of IMGs in order to triangulate the data.

In summary, our study findings are the first Canadian psychiatry needs-assessment pertaining to IMG-specific training needs during the transition into residency training. The needs-assessment results will be used to develop an IMG-specific orientation curriculum, which will supplement orientation programs offered for all medical and surgical disciplines at the University of Toronto. Based upon our needs-assessment data and current literature review, we intend to develop the following curriculum topics to prepare IMGs in our program (Table 3). The curriculum would complement a pre-existing IMG orientation curriculum for IMGs in all medical and surgical specialties at our institution and target psychiatry-specific topics highlighted by our survey. Furthermore, the curriculum would include an introduction to the teaching techniques and educational structure of North American residency programs, in order to orient IMGs to the teaching techniques used in the curriculum.

In the field of psychiatry, our reliance on language and our appreciation of the bio-psycho-social-cultural formulation requires a greater in-depth understanding of the training setting and city. Therefore, a preparatory curriculum may be able to bridge IMG gaps in training early and facilitate a more rapid transition into their residency training program. We would hope that more formal and rigorous preparatory courses for psychiatry IMGs early in their residency training will translate into improved performance immediately and in the long term during residency training. Ongoing mentorship may be beneficial in identifying cultural challenges and provide ongoing support to IMGs within the program (12). Future studies are needed to determine the effectiveness of proposed curricula and resources in improving IMG transition into psychiatry residency.

We thank the survey working group, and, especially, Drs. N. Roberts, M. Hasnain, H. Haensel, T. Callanan and K. Skakum, J. Parent, and the postgraduate office administrative staff for each program for their assistance with survey dissemination. We also thank the Canadian Psychiatric Association Membership Affairs Committee and Members-in-Training Committee for their input in this project. We appreciate the time and effort of the participating international medical graduates from the five psychiatry residency programs.