Assessment of international medical graduate surgeons in Australia

International Medical Graduate surgeons (IMGs) in Australia have a high failure rate in medical specialist certification exams. Records were examined from the Royal Australasian College of Surgeons (RACS) between 2004 and 2008 and found that IMGs failure rate is 52% compared with 30% for Australian surgical trainees. It is essential for IMGs to pass the certification exams in order to be able to practice independently as specialist surgeons. From a workforce perspective increased numbers of fully certified specialist surgeons are needed in Australia particularly in rural and regional areas to fill healthcare delivery needs. The reason for the high failure rate was uncertain so a sequential mixed methodology of inquiry was undertaken in 2008 and 2009 to research this question. The overall research design was participatory action research. It consisted of several cycles of inquiry with results from each cycle in turn informing the next. It involved a survey of IMGs obtaining both quantitative and qualitative data, a component score analysis of the IMGs examination results, a workshop for RACS decision makers obtaining qualitative data and a workshop for Supervisors of IMGs being evaluated. Social learning theories form the scaffolding on which the research was planned and the results interpreted. The reason for the high failure rate for IMGs relates to professional isolation that occurs for IMGs in rural and regional settings. IMGs need to form communities of practice and be accepted as legitimate peripheral participators in order to prepare for and succeed in the specialist certification assessments. In order for this to happen they should establish face-to-face relationships with peers, supervisors and the educational institution responsible for the assessment process. IMGs should spend the first 3 months of their clinical placement at a Metropolitan tertiary hospital to undergo initial clinical assessment and also the last 3- 6 months prior to their presenting for the Fellowship exam. When in the rural/regional setting they should regularly participate in videoconferencing with peers and supervisors or have time off to attend clinical workshops and meetings. There is a ‘hidden curriculum’ tension underlying IMG surgeon assessment as it relates to the perception by decision makers that IMGs are competing with RACS surgical trainees for hospital positions and places in exam preparatory activities. A new integrative model is proposed for IMG assessment preparation. This model consists of essential components necessary to improve IMGs success in the Fellowship certification exam. These components are good supervisor and mentor relationships, effective information dissemination from the educational institution (RACS) and appropriate policies and procedures. Peer learning is essential and understanding of individual self efficacy is important. The hidden curriculum requires further explicit discussion of beliefs and attitudes of stakeholders. The improvement in success rate for IMGs achieving full surgical certification will ensure more specialist surgeons are available in regional hospitals and improvement in quality and safety in delivery of specialist surgical services for Australia.