International Medical Graduates Research Articles

The US Residency Selection Process After the United States Medical Licensing Examination Step 1 Pass/Fail Change: Overview for Applicants and Educators.

The United States Medical Licensing Examination (USMLE) Step 1, arguably the most significant assessment in the USMLE examination series, changed from a 3-digit score to a pass/fail outcome in January 2022. Given the rapidly evolving body of literature on this subject, this paper aims to provide a comprehensive review of the historical context and impact of this change on various stakeholders involved in residency selection. For this, relevant keyword-based searches were performed in PubMed, Google Scholar, and Scopus to identify relevant literature. Given the unique history of USMLE Step 1 in the US residency selection process and the score's correlation with future performance in board-certifying examinations in different specialties, this scoring change is predicted to significantly impact US Doctor of Medicine students, US Doctor of Osteopathic Medicine students, international medical graduates, and residency program directors, among others. The significance and the rationale of the pass/fail change along with the implications for both residency applicants and educators are also summarized in this paper. Although medical programs, academic institutions, and residency organizing bodies across the United States have swiftly stepped up to ensure a seamless transition and have attempted to ensure equity for all, the conversion process carries considerable uncertainty for residency applicants. For educators, the increasing number of applications conflicts with holistic application screening, leading to the expected greater use of objective measures, with USMLE Step 2 Clinical Knowledge likely becoming the preferred screening tool in lieu of Step 1.

Mistreatment and Wellness Among International Medical Graduates in US General Surgical Residency

This study uses data from a cross-sectional national survey of medical residents in the US to assess whether mistreatment experiences and wellness differ between international medical graduates and US medical graduates.

Comparison of academic productivity and funding support between United States and international medical graduate vascular surgeons

ObjectiveThe demand for vascular surgeons in the United States stands to far exceed the current supply. International medical graduates (IMGs) are not only vital to meeting the country’s growing health care needs, but also help to advance clinical research and medical education in the field of vascular surgery. Nearly 17% of practicing vascular surgeons in the United States are IMGs, yet little is known about their relative contributions to academic vascular surgery. Our study aims to compare the academic profiles and funding support for IMG vascular surgeons to that of their US medical graduate (USMG) counterparts. MethodsA cross-sectional study was performed on all IMG and USMG academic vascular surgeons practicing in US-based hospitals with vascular surgery residency and/or fellowship programs. In addition to the baseline surgeon characteristics, academic profiles and research output were also collected. Furthermore, the National Institutes of Health (NIH) research reporting tool and open payments database were queried for any funding/payments to surgeons in both groups. Matching for year of vascular surgery training program graduation was performed where appropriate. ResultsA total of 908 academic vascular surgeons were included; 759 (83.6%) were USMGs and 149 (16.4%) were IMGs. The median year of graduation was comparable between the two groups, but USMGs had a significantly higher proportion of female surgeons (23.6% vs 10.7%; P = .0003). There were no significant differences in the academic profiles and leadership positions between the two groups. Although research productivity is similar between the two groups, IMG surgeons were more likely to have first or senior-authorship papers (47.1% vs 37.5%; P < .001). Additionally, faculty departments chaired/cheifed by a USMG were less likely to be staffed with IMG vascular surgeons (1.6 surgeons vs 3.1 surgeons; P < .0001). Following grant analysis, USMG surgeons received more NIH R01 grants (5.7% vs 1.3%; P = .026). R01-funded surgeons had significantly greater research output by number of publications (121.0 vs 47.5), citations (3872 vs 938), H-index (32.0 vs 17.5), and average journal impact factor (>10: 86.7% vs 33.3%) (all P < .001). ConclusionsThe efforts to further diversify vascular surgery are vital to better serving an increasingly diverse US population, amid growing disparities in health care. Although IMGs account for a minority of academic vascular surgeons, and contribute significantly to their published research, they had less NIH R01 funding, warranting further investigation.

Effect of Faculty Diversity on Minority Student Populations Matching into Orthopaedic Surgery Residency Programs.

The American Orthopaedic Association's Orthopaedic Residency Information Network database was used to collect demographic data on 172 US residency programs. Linear regression analyses were performed to determine the relationship between the proportion of female or URiM attendings at a program and the proportion of female, URiM, or IMG residents or top-ranked applicants (≥25 rank). URiM was defined as "racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population." A mean of 13.55% of attendings were female and 14.14% were URiM. A larger fraction of female attendings was a positive predictor of female residents (p < 0.001). Similarly, a larger percentage of URiM attendings was a positive predictor of URiM residents (p < 0.001), as well as of URiM (p < 0.001) and IMG (p < 0.01) students being ranked highly. There was no significant association between URiM attendings and female residents/overall top-ranked applicants, or vice versa. Residency programs with more female attendings were more likely to match female residents, and programs with more URiM attendings were more likely to highly rank URiM and IMG applicants as well as match URiM residents. Our findings indicate that orthopaedic surgery residencies may be more likely to rank and match female or URiM students at similar proportions to that of their faculty. This may reflect minority students preferentially applying to programs with more diverse faculty because they feel a better sense of fit and are likely to benefit from a stronger support system. III.

Analyses of Orthopaedic Surgery Residency Interviews.

We retrospectively reviewed the 2020-2021 and 2021-2022 residency interview cycles, both conducted virtually due to the COVID-19 pandemic. Residency application (i.e., applicant demographic and academic backgrounds) and interview data (i.e., faculty interviewer scores) were recorded. Interobserver reliability among faculty interviewers was calculated. Statistical analysis was performed to determine factors associated with ranking of applicants. There were 195 included applicants from the 2020 and 2021 interview cycles. There was no true agreement of interviewers' scoring of shared applicants (kappa intraclass coefficient range 0-0.2). Applicant factors associated with being ranked include applying to the match for the first time, USMLE Step 1 and 2 scores, educational break (vs. consecutive completion of college and medical school in 4 years each), higher class rank, and greater interviewer scores. Factors associated with better rank included additional degrees (i.e., PhD or MBA), couples match, AOA designation, educational break, underrepresented minority status, and notable attributes (i.e., collegiate athletics or Eagle Scout participation). Factors associated with worse rank included male sex, international medical graduate, prior match history, science major, extended research (i.e., >1 year spent in a research role), and home medical school students. There was significant variability and no reliability at our institution among faculty interviewers' applicant ratings. Being ranked was based more on academic record and interview performance while final rank number seemed based on applicant qualities. The removal of merit-based objective applicant measurements offers challenges to optimal residency applicant and program match. III (retrospective cohort study).

A Comparison of Match Rates to Orthopaedic Surgery Residency Programs Between First-Time Versus Repeat Applicants: An Analysis of the National Resident Matching Program Data from 2018 to 2022.

Data were obtained from the National Resident Matching Program from 2018 to 2022. For each year, the total number of applicants to orthopaedic surgery residency programs was obtained, as well as the number of applicants who successfully matched into orthopaedics. The match rate was compared between first-time vs repeat applicants. A subanalysis was performed on allopathic graduates (MDs) and osteopathic graduates (DOs)/international medical graduates (IMGs). In addition, the match rate for first-time applicants and reapplicants was compared between MD and DO/IMG applicants. Overall, there was a significantly higher match rate among first-time applicants (89.8%) vs. repeat applicants (22.5%, p < 0.0001). When substratified by MD and DO/IMG applicants, first-time applicants still matched at a significantly higher rate than reapplicants within each group (p < 0.0001 for each). Among first-time applicants, MDs (93.1%) matched at a significantly higher rate than DOs/IMGs (68.6%, p < 0.0001). Among reapplicants, DOs/IMGs (25.3%) matched at a significantly higher rate than MDs (20.1%, p < 0.01). First-time applicants to orthopaedic surgery residency programs have a significantly higher rate of matching compared with reapplicants, irrespective of degree. In recent years, first-time MD applicants have matched at a significantly higher rate than first-time DO/IMG applicants.

English Language Medical Schools in China: An Analysis of International Medical Graduates Practicing in the UK.

From 2006, the Ministry of Education in China has approved universities to provide undergraduate medical training in English, targeting fee-paying international students. Students on these courses can face challenges in their clinical training, particularly in the domains of communication and professionalism. This study examines the proportion of doctors qualified from such medical schools who are currently listed on the UK medical register. The UK General Medical Council register of medical practitioners was searched to identify doctors qualified from 33 Chinese medical schools who provide education in the English language. As of February 2022, 502 doctors whose primary medical qualification is from a university offering English language education in China were registered on the UK medical register. Four hundred twenty-five (84.7%) of these doctors were aged 39 and under, approximately double the proportion of doctors in this age bracket overall. Three hundred forty nine (69.5%) were staff grade and associate specialist doctors, 109 (21.7%) were doctors in training, 36 (7.2%) were on the General Practitioner (GP) register, and 20 (4.0%) were on the specialist register. Among doctors in training, the most common specialty areas were in general practice and psychiatry that are both facing recruitment shortages in the UK at present. A small but significant number of graduates whose medical training was in the English language in China are practicing medicine in the UK. These doctors are in younger age groups than the overall medical workforce, and are less likely to be in training, and specialist or GP posts. Among those in training, a high proportion are in GP and psychiatry training and could contribute to alleviating UK medical workforce shortages. Policymakers and educators should be mindful of the growing numbers of doctors qualified from these schools, and the additional support they may require considering the unique training environments they have encountered.

The United Kingdom National Health Service through the lens of an overseas clinical observer: A reflective account based on personal experience.

This article provides insight into an aspect of the National Health Service (NHS) of the United Kingdom (UK) through the perspective of an overseas clinical observer. The NHS is a government-funded medical and health care service in the UK and has developed over the years providing a high standard of medical care and professionalism. The Clinical Observership Programme has been designed primarily for International Medical Graduates to experience how the NHS functions and the kind of services it offers. This article explores the overseas observer's experience in a surgical unit of the NHS including the organisational structure, delivery of care and challenges of the system. This article also highlights the observer's perspective of surgical care in the NHS compared to surgical care in low-resource income countries. The Clinical Observership is useful in learning about UK medical practice and gaining experience in a different cultural and professional environment. This is a reflective first-hand account based on personal experience.

Linguistic coaching: a pilot study of one-to-one near-peer coaching for international GP trainees in Yorkshire

ABSTRACT Introduction International medical graduates (IMGs) have a higher rate of examination failure and are more likely to be referred to the regulator for professional performance issues than their UK-trained counterparts. Support for IMGs to reduce differential attainment takes many forms. A pilot study to assess the feasibility and utility of early intervention to increase the support available for IMGs entering general practice (GP) training was undertaken. Method IMGs entering GP training in one UK region were offered one-to-one, near-peer linguistic coaching during their first two weeks of training. A session focusing on cultural acclimatisation, local accent and dialect using mock patient consultations was delivered and evaluated. Results The coaching was valued by the trainees and the intervention allowed very early identification of a trainee who needed further support. It was possible to identify such trainees using a non-medical volunteer student coach. Discussion Use of a non-medical, near-peer coach for one-to-one linguistic support has not previously been described for IMGs. This pilot study confirms the acceptability and utility of this approach. Early identification of trainees requiring enhanced support allows targeted interventions in a time-pressured speciality training programme. Further study with a larger-scale and longer-term coaching programme, assessing trainee feedback and uptake of early supportive intervention is recommended.

“We're IMGs, and we're often seen as human garbage outside of primary care”: A qualitative investigation of dynamic status hierarchy construction online by medical trainees

In the United States health care system, “USMDs,” or allopathic US-trained medical graduates, are generally considered higher status than “non-USMDs,” or osteopathic and international medical graduates (also abbreviated as IMGs). Two key aspects of this professional hierarchy have yet to be understood: one, how it is socially and culturally reproduced during specific medical training timepoints, such as the US residency placement cycle; and two, how changes within this hierarchy may be occurring among the new generation of medical trainees and professionals. To answer these questions, I qualitatively analyzed comments from a selection of medical student Reddit posts, called “Name and Shame,” where users discussed their experiences with discrimination and mistreatment during residency interviews spanning 2018 to 2020. From this analysis, I found that after exposure to and discussion of stories of applicant mistreatment, while some students on the forum reproduced this professional hierarchy, others rejected this inequality, with non-USMD users advocating for themselves and USMD students supporting their lower status peers. These findings highlight that the construction and understanding of this USMD/non-USMD hierarchy may be more dynamic than previously thought, especially among contemporary trainees now entering the medical profession.

Supporting International Medical Graduates in Rheumatology: A Call to Action.

Supporting International Medical Graduates in Rheumatology: A Call to Action.

Predictors of matching into an ophthalmology fellowship for international medical graduates: a San Francisco match analysis.

To describe the characteristics and outcomes of international medical graduates (IMGs) applying for ophthalmology fellowship match. Design Case control study. Setting San Francisco Fellowship Match data between 2010 and 2017. Participants IMGs applying for ophthalmology fellowships. Main outcome(s) and measure(s) Applicant characteristics for IMGs were stratified by their match outcome and compared using Chi-Square and Mann-Whitney U test. A multivariable logistic regression model was used to assess the effect of applicant characteristics on their match outcomes. 22.62% (785/3471) of the fellowship match applicants were IMGs of which 35.92% (n = 282) matched. This rate was 58% lower than the 86.4% match rate for US-MG (p < 0.001). Factors associated with higher odds of matching among IMGs were graduating from a US residency (Odds Ratio (OR):2.330; 95% Confidence Interval (CI):1.433-3.789), higher USMLE Step 3 score (OR:1.019;95% CI: 1.006-1.032), applying to more programs (OR:1.035;95%CI: 1.017-1.053), ranking more programs (OR:1.200; 95% CI:1.096-1.313) and having a higher percentage of programs ranked (OR:1.021;95% CI: 1.014-1.028). Fellowship match rates for IMGs were significantly lower than for US-MGs. IMGs graduating from an ophthalmology residency in the US, scoring higher Step 3 scores, distributing more applications, and ranking more programs had increased odds of matching. This information may assist IMG fellowship applicants and their mentors when they consider pursuing an ophthalmology fellowship program in the US.

Reported Visa Acceptance or Sponsorship for Non-US Citizen Applicants to US Internal Medicine Residency Programs.

Non-US citizen international medical graduates (IMGs) make up a significant proportion of the physician workforce, especially in physician shortage areas and specialties. IMGs face barriers matriculating in US residency programs. Whether a program reports accepting J-1 visas and sponsoring H-1B visas influences their decision to apply, it remains unclear which institutional factors shape programs' likelihood to consider visa-seeking applicants. We investigated factors associated with programs reporting accepting J-1 visas or sponsoring H-1B visas for non-citizen applicants in internal medicine, the specialty most sought after by IMGs. We performed multivariable regression analyses using publicly available data to identify characteristics associated with reported visa acceptance (J-1 and or H-1B). Covariates included university affiliation, program size, program type (academic, university-affiliated community, or community), and Doximity reputation ranking. We identified 419 programs: 267 (63.7%) reported accepting J-1 visas. Among programs that accepted J-1 visas, 65.6% (n=175) accepted only J-1 visas while 34.5% (n=92) sponsored H-1B and accepted J-1 visas. Ranking in the third quartile (vs first quartile) was associated with lower odds of accepting J-1 (aOR 0.12; 95% CI 0.02-0.87; P=.04) and sponsoring H-1B visas (aOR 0.19; 95% CI 0.05-0.76; P=.02). Community status (vs academic) was associated with lower odds of accepting J-1 visas (aOR 0.2; 95% CI 0.06-0.64; P=.007), as was county hospital affiliation vs non-county hospitals (aOR 0.22; 95% CI 0.11-0.42; P<.001). While prior evidence shows that most internal medicine programs that substantially enroll IMGs are low ranking, high-ranking internal medicine programs are paradoxically more likely to report that they consider and sponsor visa-seeking applicants.

International Briefs

International Briefs

Personal Psychotherapy Prepares Trainees to Be Better Psychiatrists, Educators Say

Personal Psychotherapy Prepares Trainees to Be Better Psychiatrists, Educators Say

The Virtual Interview Experience: Advantages, Disadvantages, and Trends in Applicant Behavior.

A survey was distributed to 302 applicants to a single plastic surgery residency program during the 2020 application cycle. Demographics, social media presence and utilization, and experience with the virtual application and interview process were analyzed. A 2018 survey from our institution was compared with a subset of questions for longitudinal analysis. Seventy-six respondents (25.2%) completed the survey. Most applicants (88.2%) spent less than $1000 during the interview and application cycle. Over half (56.6%) did not receive letters of recommendation from outside their home program. A significant minority (27.6%) of applicants attended more than one interview in a single day. Compared to 2018, applicants in 2021 were significantly more likely to access alternative digital resources (forums/discussion boards, social media, and podcasts) when learning about programs. Average number of interviews remains in the range of pre-COVID studies, but the percentage of interviews attended increased. Applicants spent substantially less money on interviews and relied on alternative digital sources to learn about residency programs. This study objectively quantifies the advantages of virtual interviews. Disadvantages include inability to assess "fit" and lack of nonverbal communication.

Graduates of a Multidisciplinary Critical Care Training Program from 2000 to 2020: Looking at Their First Job.

Little is known regarding the career paths of adult multidisciplinary critical care medicine (CCM) fellowship graduates. The purpose of this study is to describe the demographic profiles and characteristics of the first jobs held by internal medicine-CCM fellowship graduates trained at a freestanding cancer center. An electronic survey was developed via Research Electronic Data Capture that addressed first employment parameters and was sent between May 1, 2019, and December 31, 2021, to 133 CCM fellows who completed CCM fellowship training from 2000 to 2020 at our institution. A total of 93 fellows (70%) responded to the postfellowship job survey; 80(60%) with complete responses were analyzed. Seventy-four percent of respondents were men, 41% were White, 81% were international medical graduates, and 31% were holders of J-1 exchange visitor (n = 8) or H-1B (n = 17) visas. The mean age at completion of CCM fellowship was 36 years. Twenty-seven respondents (34%) completed two years of fellowship training and 53 (66%) completed one year. Internal medicine was the primary residency training before CCM fellowship for 75 respondents (94%) and emergency medicine for 5 (6%). Of those who did one year of fellowship (n = 53), 45 (85%) had already completed two-year fellowships in pulmonary medicine. Thirty-two respondents (40%) completed training from 2000 to 2009 and 48 (60%) from 2010 to 2020. The first employment for the majority (>80%) of graduates was in community teaching hospitals. Of the graduates who spent ⩾50% of time clinically in CCM, 85% rounded in multiple intensive care units (ICU). Compensation sources were from hospitals for 81%, private billing for 15%, and through faculty practice plans for 4% of respondents. At the time of survey completion, 51 respondents (64%) were still at their first jobs; of these, slightly more than half (56%) had graduated from the fellowship program in the past 10 years. The majority of CCM fellowship graduates from our program practiced CCM at community teaching hospitals, rounded in multiple ICUs, and were compensated primarily by the hospital.

Can a novel blended learning resource improve the simulation experience for international medical graduates working in the UK? A survey of kent surrey sussex trainees in anaesthesia

With the increasing number of International Medical Graduates (IMGs) hired by the UK National Healthcare Service (NHS), a unification of training becomes essential. One of the main obstacles facing IMGs is insufficient simulation-based training [1]. In 2021, 19,977 doctors were registered to the General Medical Council (GMC). 10,009 of them studied medicine outside the United Kingdom (UK) [2]. Blended learning offers the opportunity for engagement and interaction to facilitate learning experiences [3]. We created and distributed a survey to Anaesthetic trainees in the ‘Kent Surrey Sussex (KSS)’ Deanery. We received a total of 76 responses, 49 (64.5%) UK graduates (UKGs) and 27 (35.5%) international graduates. The survey was designed to ascertain their medical training, simulation experience, and their perception of that simulation experience. We also included additional questions aimed specifically at IMGs to demonstrate the best way they could be supported to acquaint themselves with the simulation process further. IMGs were less likely to have simulation training as an undergraduate (24% IMGs vs 96% UKGs), and 37% of IMGs had no simulation exposure before coming to the UK. IMGs were also exposed to fewer simulation sessions during their career when compared with UKGs. When asked how simulation can improve human factor variables, including teamworking, leadership, and managing stressful situations, both groups responded similarly. An exception was that IMGs were much more likely to ‘strongly agree’ that simulation improved their communication skills (41% vs 29%). IMGs were less likely to find the overall simulation experience ‘excellent’ (24% vs 51% in UKGs), suggesting more can be done to improve their perception of simulation ( Comparison of UKGs versus IMGs simulation experience. As well as asking about how simulation improved communication skills, responders were asked the impact simulation had in improving other core skills including teamwork, leadership, and managing stressful situations with both groups responding similarly. There is a clear discrepancy in simulation exposure and perception of simulation between IMGs and UKGs. We believe blended learning may be the solution to help bridge this gap. Our survey highlighted potential resources we can introduce, including introductory videos, additional learning materials, and attending simulation as an observer. We hope to incorporate some of these in the future within our Trust Simulation Department and, if successfully received, expand throughout the KSS deanery. 1. Martinerie L, Rasoaherinomenjanahary F, Ronot M, Fournier P, Dousset B, Tesnière A, Mariette C, Gaujoux S, Gronnier C. Health care simulation in developing countries and low-resource situations. J Contin Educ Health Prof. 2018;38(3):205–212 2. Campbell D. NHS hiring more doctors from outside UK and EEA than inside for first time. The Guardian. 8 June 2022. 3. Singh H. Building effective blended learning programs. Educational Technology. 2003; 43:51–54

Use of high-fidelity simulation to ensure inclusivity and equality of international medical graduates

The UK medical profession is becoming increasingly diverse as the number of international medical graduates (IMGs) joining the UK medical workforce increases every year. However, IMGs face a number of significant sociocultural and educational challenges. Recent studies show that IMGs lack insight into the system and lack clarity in relation to the role of a supervisor, career pathways, and medico-legal and ethical issues [1,2]. They exhibit differences in clinical practices and team dynamics. Recent studies suggest the introduction of dedicated induction programs in the form of formal teaching sessions, or tailored online induction for IMGs prior to their first job [1–3]. Most IMGs have minimal exposure to simulation and human factors training with international medical schools favouring more didactic methods of education. We have designed a high-fidelity simulation course with frequently encountered clinical scenarios to improve inclusion and a harmonious transition for the IMGs. This provides an opportunity to familiarise themselves with the healthcare system and team dynamics within the NHS and instils confidence to perform to the best of their ability in their respective roles. The course has been designed specifically tailored to the needs of IMGs who may find it daunting at first to make their place in a completely new system. We employ high-fidelity simulation encompassing multiple frequently encountered clinical scenarios. The scenarios are followed by a debriefing, with a special focus on human factors, interpersonal and communication skills, and understanding of authority gradients. The attendees are also encouraged to reflect on their performance and to participate in the discussion, share their professional opinions, experiences, and cultural influences. The attendees are asked to fill a pre-course and post-course questionnaire. Two pilot courses were conducted with a total of 22 attendees. Pre- and post-course feedback with reflective questions about various aspects of the course was obtained. The scenarios assessed 5 categories, which the IMGs graded on a Likert scale. Pairwise comparison was performed between pre- and post-course feedback, showing a statistically significant increase in confidence levels related to all assessed categories; basic management skills (p &lt;0.001), clinical skills (p=0.006), communication skills (p&lt;0.001), teamwork (p&lt;0.001), and leadership (p&lt;0.001). Based on the positive feedback from attendees we believe that this induction simulation course can greatly help IMGs have a smooth transition into the NHS, and ensure inclusivity by equipping them with confidence, a knowledge of the system, and human factors. 1. Rasquinha M. Difficulties and educational challenges faced by international medical graduates in trust grade roles in the UK. British Journal of Hospital Medicine. 2022;83(4):1–7. 2. Hashim A. Educational challenges faced by international medical graduates in the UK. Advances in Medical Education and Practice. 2017;8:441–445. 3. Emery L, Jackson B, Oliver P, Mitchell C. International graduates’ experiences of reflection in postgraduate training: a cross-sectional survey. BJGP open. 2022.

Reflections on our experiences of delivering a simulation-based education programme for medical support workers

International Medical graduates (IMGs) contribute significantly to the NHS medical workforce, but often face unique challenges which are not always catered for within medical education [1]. The Medical Support Worker (MSW) role was created in response to the COVID-19 pandemic, providing an opportunity for doctors seeking GMC registration to gain clinical experience within a supervised NHS placement [2]. Our Trust’s Postgraduate Medical Education department was asked to deliver a teaching programme to the Trust’s first cohort of 29 MSW’s, 28 of whom are from Myanmar. The aims of this programme were to provide support for the MSW role and preparation for working as an NHS doctor. Based on a scoping questionnaire of the MSWs’ perceived learning needs and our prior experiences of working clinically with IMGs, we developed an innovative tailored programme, consisting of three days covering frequently-encountered clinical scenarios, non-technical, procedural and communication skills. Throughout the teaching programme, several themes unique to MSWs became apparent. These learners’ previous experiences of medical education were predominantly behaviourist, consisting of didactic teaching in which learner contribution was not encouraged. Their only prior experience of simulation was for assessment. It was therefore vital that we ensured a psychologically safe environment in which they felt confident and were encouraged to participate in near-peer learning. We achieved this by explicit conversations about different styles of medical education and modelling these behaviours consistently. A particular challenge we encountered was introducing the learners to the hidden curriculum of the NHS [3]. This refers to the behaviours and values that form an acceptable professional identity and may differ between international healthcare systems. It became apparent during simulation that dedicated human factors training would be valuable. This was integrated via two half-day sessions focussing on non-technical skills and communication-based simulation. Cultural differences, especially in communication styles, became apparent. This included: a doctor-centred versus patient-centred agenda; challenges inherent to communicating in a second language; and different cultural values and legal frameworks. We endeavoured to expose our learners to scenarios that provoked discussions around these issues, for example communicating with a teenager requesting contraception. IMGs face unique challenges when entering the NHS workforce and it is inherent upon medical educationalists to consider and meet these needs. We have identified three major themes (different educational models; the hidden curriculum of the NHS; and cultural differences) that must be addressed to ensure high quality care and patient safety. 1. 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: 105:157 –165 2. Temporary Medical Support Worker (MSW) Secondary Care – Job description and person specification. NHS England and NHS Improvement. 3. Hafferty FW, O’Donnell JF. The Hidden Curriculum in Health Professional Education. 2014.Hanover, NH: Dartmouth College Press