Grounded theoretical framework: categories from selective coding identifying reasons for differential attainment comparing UK and international medical graduates
| Theme 1: ‘theoretical versus real-life clinical experience’ | Classroom versus clinical experience: ‘You need theory obviously but the practical exposure makes you remember because there is so many things to remember in medicine.’ [Participant B8, Female, IMG] Clinical exposure to minor specialties: ‘To be honest with this particular question, I haven’t seen a vulva inflamed with ulcers. It’s more my, the clinical approach that medical training has given me to say a patient presenting with these symptoms what is the likely cause’. [Female, BME UKG]. ‘Because for some people if you are coming from outside Europe, and if where you weren’t trained, they haven’t got access to all that, you wouldn’t know actually what they are talking about. They don’t see any CT in real life. The knowledge about it is just like my teacher taught me while standing in front of the board, in front of the classroom. Something called CT.’ [Male, IMG]. Memorisation and rote learning ‘We are taught to memorise things. Even if they don’t make sense. The more you memorise, the better. So we used to memorise all the doses and names. Which is not really important here because they have got the British National Formulary (BNF). Here you are more supported or things out of the books. [Female, IMG]. |
| Theme 2: ‘recency, frequency, opportunity and relevance’ | Recency ‘I’ve got no clue currently. I haven’t worked in paediatrics or come across this. When I was in basic training seven years ago [overseas], that’s the time I read about vaccinations. I have forgotten.’[Male, IMG]. ‘Not really necessarily part of gynaecology. I haven’t come across this sort of question since medical school.’[Male, BI/UKG]. Frequency, repeated exposure: ‘Getting exposed to many different patients makes it easier to remember.’ [Female, IMG]. Limited opportunity for experience: ‘I’m not going to be doing a rotation through that. So whatever I’m going to get out of it will be personal study and gynaecological patients that come into the practice that I see and discussion with my trainers’ [Male, IMG]. Gender barriers: ‘I think female doctors in practice tend to see more gynae related issues. It’s less awkward to be examined by a female than by a male. I’ve also heard about risk of complaint against the male doctor to sensitive females.’ [Male, IMG]. ‘I don’t really deal with prostate problems much being a lady doctor.’ [Female, BI/UKG]. ‘I’ve certainly seen a few ladies in the last few weeks with vaginal discharge.’ [Female, BME UKG]. Uncommon presentations ‘Neurology, I’m not sure in regard to AKT which is a paper exam. More like facing an actual patient. Neurology is a difficult specialty’. [Female, IMG]. Relevance to general practice: ‘Because I feel we don’t get much training regarding eye questions in GP. When I speak to my other GP colleagues and trainers, they tell me they are not very confident themselves. And they tend to refer most of them to opticians. Who will then refer to ophthalmologists as required?’[Male, IMG]. ‘I think it’s more a nurse’s role. The midwife.’ [Male, IMG]. Statistical relevance ‘I’ve done statistics before not things they used in medicine and clinical trials. Sensitivity and specificity. That was new to me.’[Female BI/UKG]. ‘As an undergraduate I never went through statistics No!’[Male, IMG]. ‘This is just looking at data. I would never be asked this question. I can’t imagine I would ever be asked this by a patient’ (Male UKG). ‘Most of the time (statistics) I don’t need it in real life’. [Female, IMG]. ‘Because I studied overseas, we didn’t have much statistics. When we actually started studying for AKT, we got to know that we need to study statistics.’ [Female, IMG]. ‘You won’t get scared but already looking at this I’m getting scared. Looking at these numbers.’ [Male, IMG]. Exam Scenario: ‘This is more of an exam scenario because I would just have to be able to know it whereas in real life I can look it up with the patients.’ [Female, B/I UKG]. ‘I would find this question more appropriate for real practice if I had been asked a patient has this symptom and these are the possible investigations that you can do, which one would you do?’ (BME UKG). |
| Theme 3: ‘competence and insight’ | Perception of competence: ‘Ok, drug side effects. I think I’m excited about this one. It has a lot to do with pharmacology drugs which I like. I like looking at the BNF and drug books just to look at the side effects. Just looking at this topic of drug side effects, even though I have not gone through it, I think I feel a bit confident ……Definitely it’s going to be A’. [Male, IMG]. ‘So immediately it’s a thirty year old lady and again I’m comfortable answering this question perhaps more than male doctors because I get this problem presented to me. Not exactly this case but I have had this type of problem before presented in clinics. Before even looking at the options, it strikes me as a risk of an STI.’ [Female, B/I UKG]. Biased self-evaluation ‘I like these ones (item stems, drug side effects) because they are straightforward. Only one can be correct….I’ve read about it. Done it in questions. Presented in surgery. I’m doing psychiatric now, and I’ve actually seen someone Actually on a day to day basis’ [Male, IMG]. ‘Yes, they are common drugs. All things I am familiar with. Atenolol, I prescribe every day.”[Male IMG]. |
| Theme 4: ‘cultural barriers’ | Unfamiliarity with the NHS: ‘If you are not familiar with the system, you don’t know what services are available.’ [Female, IMG]. Abbreviations: ‘And even the simplest things. Abbreviations for example. Talking about patients. We don’t use abbreviations a lot from where I come from.’ [Female, IMG]. Unfamiliar working in a clinical framework: ‘I think guidance are used more in the UK. So I still have to read a lot of guidance. Back where I trained, I don’t think national guidelines apply.’ [Male, IMG]. National guidance: ‘Because I was trained overseas, the Ghana is quite different to what it is over here. Coming to work in the UK, you need to be working with the NICE guidelines. So I have not been, when I was in training, I have not been introduced to it. So it is a new thing I have been picking up after my graduation while working in the UK.’ [Male, IMG]. Exam formats: ‘Because of that you may not get the right answer. Most of us who are not trained here when we read the question will have got a bit of three way translation. We understand the English but we are thinking in our own native language’. [Male, IMG]. ‘I trained in Russia in Russian language [native language African], so sometimes I have to think allowed and try to process the information before I totally understand it.’ [Female, IMG]. |