Orientation involves “an introduction, as to guide one in adjusting to new surroundings, employment, activity, or the like” (1). This process is particularly salient for International Medical Graduates (IMGs). In Canada and the United States (U.S.), an IMG refers to a physician who obtained his/her basic medical degree at a medical school outside of Canada or the U.S. (2). In 2010–11, IMGs accounted for about 30% of all postgraduate Year 1 (PGY1) residents in psychiatric programs in the U.S. (3). Given the significant representation of IMGs in psychiatry training programs, it is important to recognize the needs of this group of trainees (4).

IMGs bring many assets to training programs, including knowledge of other healthcare systems and unique cultural lenses. Along with these assets, IMGs also face significant personal and professional challenges. Some authors have proposed that the process of adaptation for IMGs may involve traversing through phases of loss, followed by disorientation (5), as migration may precipitate significant crises and shifts in an individual’s identity (6, 7). Moreover, IMGs who immigrate with their families may feel responsible for helping them to acculturate. Communication—verbal, nonverbal, and written—present particular challenges for IMGs from non–English-speaking countries. Lack of familiarity with idioms, nuances, and colloquialisms can have an impact on learning and clinical interactions (8–10). IMGs must also navigate healthcare systems infused with sociocultural values with which they are unfamiliar or that are discordant with beliefs in their countries of origin. Other potential areas of discordance include differences in gender roles, authority, and the role of physicians (11).

Currently-established orientation programs that assume fluency in English and familiarity with Western culture and do not explicitly address the impact of immigration may serve to exacerbate the disorientation of IMGs’ experience (12). This has been our experience in training IMG fellows in a 1-year clinical fellowship in psychosomatic medicine at the University Health Network, a teaching hospital affiliated with the University of Toronto. Negotiating the dynamics that evolve in an interdisciplinary tertiary/quaternary care setting involves higher-order integration of multiple competencies, all within a milieu in which IMG fellows are already grappling with the acculturation process. The challenges we experienced with our IMG fellows prompted us to re-examine not only the orientation process but also the ways in which we approached their education.

The TLC (Teaching for Learning and Collaboration) Program, a clinical teaching skills-development program developed at the Centre for Faculty Development at the University of Toronto, provides an approach for teachers seeking instruction regarding teaching behaviors to improve their teaching practice. TLC focuses on methods to engage students and improve the student learning experience. From a theoretical perspective, the TLC Program is informed by social constructivism, andragogy, and reflective practice (13). Social constructivism, in this context, refers to learning that occurs through the creation of meaning in social interactions (14). Part of the acculturation process may involve experiencing a new way of teaching and learning, in which learners are encouraged to collaboratively discover their own meaning from the content before them. Andragogy refers to the process of learning in adults that recognizes the importance of contextualizing new information based on a learner’s past experiences, fostering self-direction and internal motivations to learn.

At the University of Toronto in the 2007–08 academic year, IMGs from over 70 countries comprised 72% (755) of the 1,055 clinical fellows in the Faculty of Medicine; furthermore, this number increased 169% over a 10-year period (15). In the 2010–11 academic year, 30% of all psychosomatic fellows in the U.S. were IMGs (3). As psychosomatic medicine is not yet an accredited program in Canada, there are no formal data available on the number of IMG fellows in Canadian psychosomatic medicine programs.

Although there is a growing body of literature addressing the personal and professional needs of IMGs enrolled in residency programs, there is a paucity of literature on IMGs completing fellowship training. Given fellows’ advanced level of training, there is often the expectation that they function in leadership and teaching roles. Expectations that IMG fellows, much like their Canadian or U.S.-trained counterparts, function in such roles initially may prove stressful for the fellow and lead to inaccurate assessment of the fellow’s capacities (11). Educational strategies that have been suggested to address IMGs’ learning and developmental needs include more structured forms of instruction and explicit feedback, closer supervision and observation, and establishing mentoring relationships (16). Although such strategies may be useful, it is not clear where to begin or in what context such strategies should be implemented with IMG fellows. The TLC Program provides a framework in which to implement educational strategies that is informed by the literature on effective teaching skills.

We conducted a literature review on the educational needs and adaptation process of IMG trainees. Six “modules” were originally developed in the TLC Program. For greater relevance to our setting, we modified the modules to a series of four steps. These steps are the following:

• Setting an Educational Climate

• Identifying Learner Needs and Setting Goals

• Checking In and Making Learning Stick

• Feedback

These “steps” do not exist in isolation, and the process is an iterative one: each step is predicated on the previous one and can be revisited as the trainee’s learning needs evolve (Figure 1).

The modified TLC program was piloted between 2008 and 2011 on four IMG fellows who completed a psychosomatic fellowship. Weekly meetings with supervising staff on the C–L (consultation–liaison) psychiatry service were arranged to discuss learning needs and personal challenges. In general, formal feedback was given to trainees every 3 months, with more regular feedback and opportunities to “check in” as per the fellows’ needs and observed performance.

TLC Background

Setting an Educational Climate

The educational climate refers to the “atmosphere” in which teaching and learning occurs. An educational climate should be both supportive and challenging. A supportive educational climate fosters trust, respect, and flexibility, whereas an intellectual educational climate establishes duties and standards with the understanding that mistakes and risk-taking are an inherent part of learning.

Identifying Learner Needs/Setting Goals

Identifying learning needs and setting clear goals orients the teacher and learner while fostering collaboration in terms of working toward common goals. Conducting an “Educational Experiences Inventory” is a part of this process and involves reviewing past educational and clinical experiences and expectations for training in order to identify learning needs and facilitate negotiation of goals.

Checking In and Making Learning Stick

Enhancing comprehension and retention, or “making learning stick,” involves teachers’ providing opportunities for learners to practice, integrate, and reflect on information that has been presented. “Making learning stick” also involves “checking in” with trainees through providing opportunities to demonstrate new skills and apply knowledge. This iterative process of checking in and providing opportunities for learning to “stick” may help trainees learn by asking them to retrieve and utilize information within a relevant context.

Feedback

Feedback is a complex interpersonal process that is geared toward improving performance. Moreover, it is a bidirectional process of communication that involves the sharing of experiences. Feedback regarding teachers’ observations of learners can be reconciled or contrasted with learners’ self-assessments. Moreover, it provides an opportunity for both the trainee and teacher to “take stock” of what has been accomplished, celebrate successes, and speak openly about challenges. A summary of how we have applied the TLC program to teaching our IMG fellows is presented in Figure 2.

The initial pilot of the adapted TLC Program revealed several areas that required modification or more explicit techniques. Below, we highlight the most significant findings.

Educational Climate

Daily clinical rounds present a time when trainees and supervisors interact as a group. We found that fellows often appeared quiet during these rounds. When asked about this, fellows reported that staff and residents tended to speak quickly and use multiple acronyms as well as idioms with which the fellows were unfamiliar. We therefore tried to slow down the pace as well as to explain any terms with which the fellows were unfamiliar. We also empowered fellows to indicate when they were feeling lost and to share their experiences with patients from their country of origin. These discussions often highlighted cultural differences and opened dialogue about the ways in which culture shapes medical practice. Supervisors also explicitly discussed some of the challenges IMGs and their families faced as they adjusted to Western society during weekly supervision.

Identifying Learner Needs/Setting Objectives

Identifying learner needs required an extended period of assessment—approximately 3 months—to determine gaps in knowledge and skills. Often, what appeared like a gap in knowledge or skills was actually related to the fellow’s feeling overwhelmed with the myriad of tasks involved in relocation, difficulty with language, or cultural differences in learning styles (11). As a result of what we discovered with regard to giving feedback, we also modified the manner in which we set objectives. Learning objectives were not only discussed but also written down, and a copy was given to the trainee so that they could prioritize their learning needs.

Feedback

Negative feedback is often delivered via couching it among positive feedback messages. We found this ineffective in emphasizing learning needs, as our IMG fellows tended to focus on the positive feedback and minimize areas of needed improvement—the opposite of our experience with Canadian trainees. We surmised that this may have been due to the language used to deliver “negative” feedback, which many supervisors articulated in more diplomatic terms. As such, we found that being more direct about needed improvement was more effective in communicating gaps in knowledge or skills.

Inclusion of IMGs into postgraduate medical education programs in Canada and the U.S. poses both challenges and opportunities for medical educators. Psychiatry is a relationship-based specialty that involves negotiating the at-times murky waters of interpersonal interactions and communication with patients, families, and other healthcare providers. Differences in modes of relating and communication, both verbal and nonverbal, form the backdrop for the disorientation IMGs may face as they begin postgraduate medical training in psychiatry. Although it was applied in a psychosomatic medicine fellowship setting, the TLC Program is intended to be generalizable to other settings with IMG trainees. Further evaluation of the TLC Program as applied to IMGs is required, and we are in the process of developing formal supervisor and trainee evaluations. A learner-centered approach, such as the TLC Program, may not only facilitate learning in trainees but may also expand the repertoire of skills for teachers through providing a safe “space” that allows for open dialogue about how culture affects teaching and learning.