Evaluating international graduates’ experiences of reflection in general practice training

Talk Code: 
Laura Emery
Dr Caroline Mitchell, Dr Ben Jackson
Author institutions: 
Academic Unit of Primary Medical Care University of Sheffield


Compared to their UK trained colleagues, international medical graduates (IMGs) have worse outcomes both during GP training(1), and when it comes to the RCGP membership exam(2). This differential attainment may in part be related to a lack of experience of reflection, which has been identified as key to the progression of IMGs in GP training(3,4). Reflection is a requirement for self-regulated and lifelong learning, and key in the development of therapeutic relationships and professional expertise(5). Many UK medical schools include elements of reflection in their undergraduate curricula, and UK graduates experience reflection during the UK Foundation Programme. By contrast, IMGs often have limited exposure to reflection because of the didactic methods favoured by many international medical schools(6,7).GP trainees have been shown to benefit from reflecting on difficult or challenging situations encountered in practice(8). For IMGs potential areas of difficulty in adapting to UK based practice include changing to a patient centred model of care(9) and engaging with ethical dilemmas in a different socio-cultural context(10). Awareness of socio-cultural differences encountered by IMGs through use of reflection may be key to understanding and therefore narrowing the gap in attainment.This research aims to explore IMG experiences of reflection within UK general practice training.


A stakeholder group of 3 IMG GP trainees and 3 GPs with experience of working and/or training abroad has been recruited and will be consulted through all stages of the research process. Workstream 1 is currently in progress; an online questionnaire has been developed and is currently being piloted in a small group of South Yorkshire based IMG trainees. In the week commencing the 8th March, this questionnaire will be circulated to all IMGs currently employed by UK GP training programmes through local postgraduate deaneries. Data collected will include previous experience of reflection, support available for development of reflection and benefits perceived from engaging with reflection. In Workstream 2, 15 IMG trainees will be invited to participate in a telephone interview to explore emerging themes. Participants will be purposively sampled from the pool of survey respondents and ‘snowballing’, to achieve a maximum variety sample. The questionnaire results, literature review and stakeholder feedback will be used to develop an interview topic guide.


Results from Workstream 1 are expected by April 2021.


This research will provide a greater understanding of IMGs’ experiences of reflection including what support and training, if any, they have found most useful for developing this important skill for professional development. The key to addressing differential attainment must first be to appreciate the experience of IMGs so that we can develop training which suits their needs.

Submitted by: 
Laura Emery
Funding acknowledgement: 
Application submitted to RCGP SFB for funding- awaiting outcome References 1. Tiffin PA, Illing J, Kasim AS, McLachlan JC. Annual Review of Competence Progression (ARCP) performance of doctors who passed Professional and Linguistic Assessments Board (PLAB) tests compared with UK medical graduates: National data linkage study. BMJ [Internet]. 2014;348(April):1–18. Available from: http://dx.doi.org/doi:10.1136/bmj.g2622 2. Esmail A, Roberts C. Academic performance of ethnic minority candidates and discrimination in the MRCGP examinations between 2010 and 2012: Analysis of data. BMJ [Internet]. 2013;347(7927):1–10. Available from: http://dx.doi.org/doi:10.1136/bmj.f5662 3. Warwick C. How international medical graduates view their learning needs for UK GP training. Educ Prim Care. 2014;25(2):84–90. 4. Kehoe A, McLachlan J, Metcalf J, Forrest S, Carter M, Illing J. Supporting international medical graduates’ transition to their host-country: realist synthesis. Med Educ. 2016;50(10):1015–32. 5. Sandars J. The use of reflection in medical education: AMEE Guide No. 44. Med Teach. 2009;31(8):685–95. 6. Khan FA, Chikkatagaiah S, Shafiullah M, Nasiri M, Saraf A, Sehgal T, et al. International Medical Graduates (IMGs) in the UK—a Systematic Review of Their Acculturation and Adaptation. J Int Migr Integr. 2015;16(3):743–59. 7. Pilotto L, Duncan G, Anderson-Wurf J. Issues for clinicians training international medical graduates: a systematic review. Med J Aust. 2001;187(4):225–8. 8. Emery L, Jackson B, Herrick T. Trainee engagement with reflection in online portfolios: a qualitative study highlighting the impact of the Bawa-Garba case on professional development. Med Teach. 2021;Accepted a. 9. Michalski K, Farhan N, Motschall E, Vach W, Boeker M. Dealing with foreign cultural paradigms: A systematic review on intercultural challenges of international medical graduates. PLoS One [Internet]. 2017;12(7):1–20. Available from: http://dx.doi.org/10.1371/journal.pone.0181330 10. Slowther A, Lewando Hundt GA, Purkis J, Taylor R. Experiences of non-UK-qualified doctors working within the UK regulatory framework: A qualitative study. J R Soc Med. 2012;105(4):157–65.