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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 6  |  Issue : 2  |  Page : 70-77

Residency and fellowship training programs in the United States of America: A cross-sectional survey of Saudi medical graduates


1 Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
2 Department of Neurosurgery, King Fahad Hospital of the University, Imam Abdulrahman bin Faisal University, Dammam, Kingdom of Saudi Arabia
3 Vice Rector at Princess Nourah Bint Abdulrahman University, Health Affairs and Education Matters Department, Riyadh, Kingdom of Saudi Arabia
4 Division of Neurosurgery, Department of Surgery, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia

Date of Submission23-May-2021
Date of Acceptance30-Oct-2021
Date of Web Publication12-Jan-2022

Correspondence Address:
Hanan Jaber Al-Gethami
Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, ON
Canada
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/KKUJHS.KKUJHS_23_21

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  Abstract 


Background: International medical graduates (IMGs) who study abroad face multiple challenges and more significant discrimination compared to that experienced by other graduates. These obstacles take different forms and occur in multiple stages. Furthermore, adaptation to a new culture causes several challenges for them, affecting their training and patient care.
Objectives: This study was done to evaluate the personal experiences of Saudi IMGs and to describe the challenges they encounter during their residency and fellowship training programs in the United States of America.
Materials and Methods: A cross-sectional online survey was conducted online in 2013. Participants included 230 Saudi IMGs enrolled in residency or fellowship training programs in the United States of America.
Results: The majority of the respondents were males and strongly disagreed that lack of English language proficiency was a barrier to learning. High disagreement on discriminatory criticism was most common in postgraduate year 5 (R5) and higher levels (44.8%). Most participants reported positive experiences involving the learning environment. Moreover, some participants reported that they did not find it difficult to perform their religious activities. Total 43.4% of the participants reported equality of treatment regarding administrative responsibilities. However, subgroup analysis showed that women's experiences were less favorable than those observed in the male population.
Conclusions: Results suggested that Saudi IMGs had an overall positive experience and faced minor barriers while studying in the United States of America. However, subgroup analysis showed that women's experiences were less positive relative to men.

Keywords: Fellowship, graduates, medical, residency, Saudi


How to cite this article:
Al-Gethami HJ, Al-Jehani H, AL-Saggaf S, Ajlan A. Residency and fellowship training programs in the United States of America: A cross-sectional survey of Saudi medical graduates. King Khalid Univ J Health Sci 2021;6:70-7

How to cite this URL:
Al-Gethami HJ, Al-Jehani H, AL-Saggaf S, Ajlan A. Residency and fellowship training programs in the United States of America: A cross-sectional survey of Saudi medical graduates. King Khalid Univ J Health Sci [serial online] 2021 [cited 2022 Jan 17];6:70-7. Available from: https://www.kkujhs.org/text.asp?2021/6/2/70/335629




  Introduction Top


An estimated 200,610 international medical graduates (IMGs) were practicing in the United States of America in 2013, representing 24% of the total number of physicians.[1] The American Medical Association reported an increment by almost 18% in IMGs working in the USA since 2010.[2] The National Residency Matching Program data for the year 2013 demonstrated that out of a total of 34,355 medical students and graduates who participated in the matching process, half (50.9%) of the applicants were seniors attending allopathic schools in the USA, while 12,663 (36.8%) were IMGs, accounting for more than one-third of the total number of applicants. More specifically, 5095 of the IMGs were US citizens, while 7568 were not.[3] Therefore, of the IMGs who applied, 6307 (49.8%), including 2706 (53.1%) who were US citizens and 3601 (47.6%) who were not, were matched, but 39% were not offered positions.[4],[5] Concerning Saudi medical graduates (SMGs) in the 2013 application year, total 17,837 (13,366 men and 4.471 women) were accepted. Of these, 2146 (1306 men and 840 women) and 283 (176 men and 107 women) were accepted into health sciences and residency programs. Furthermore, 230 men and women were enrolled in medical and science programs, which included residency, fellowships, master's degrees, and research positions.[6]

IMGs who study abroad face multiple challenges and more significant discrimination compared to those experienced by other graduates. These obstacles take different forms and occur in multiple stages.[7],[8],[9],[10],[11] One of the most important challenges is the language barrier, which is considered a frustrating problem and one of the reasons for discrimination.[12] These language difficulties involve history taking, abbreviations and medical terms understanding, conveying patient information, and comprehending accents.[13],[14] The overall language frustration led some IMGs to multiple negative consequences, including resource utilization, poor patient outcomes, poor residency performance, and excessive stress in dealing with patients and their relatives.[15],[16] Another important challenge is the process of adaptation to a new culture, social and cultural differences that create problems for IMGs, affect their training, patient care, and ultimately lead to failure in their medical practice.[17],[18]

No research studies have been conducted focusing on the direct examination of the barriers faced by SMGs enrolled in residency or fellowship programs. Therefore, the present study aimed to evaluate the personal experiences of SMGs, examine and evaluate the challenges they faced during their residency and fellowship training programs in the USA, and obtain information regarding the extent and types of discrimination they faced. Our hypothesis suggested that SMGs enrolled in residency or fellowship programs in the USA face discrimination and numerous barriers.


  Materials and Methods Top


Study design

A large-scale, cross-sectional online survey was conducted.

Participants

We sent E-mails to 230 SMGs enrolled in residency or fellowship training programs in the USA in 2013, inviting them to participate in the study. Participants' E-mails were obtained from the Saudi Arabian Cultural Mission (SACM) registry data containing all the contact information for Saudi international graduates. A total of 102 questionnaires were completed (response rate: 44.3%). The inclusion criteria were SMG status and enrollment in a residency or fellowship program in the USA in 2013.

Questionnaire development

The survey was developed and modified based on a literature review of similar studies by the researchers, with assistance from the SACM that constantly deals with barriers faced by IMGs in the USA.

Measurement instruments

The questionnaire consisted of 6 sections and included 28 items and 1 open-ended question. The questionnaire included four items pertaining to the participants' demographic characteristics, including sex, age, marital status, and parenthood. In addition to five items about the training details, including training program/center, current training level, the number of years spent in the USA before their enrollment in the residency program, and the number of years enrolled in training programs in the USA and Saudi Arabia. Furthermore, participants' attitudes were measured using 19 items divided into four main sections: language and communication (5 items), learning and education (5 items), social and cultural factors (5 items), and administrative issues (4 items). Responses were provided using a 5-point Likert scale ranging from 1 (strongly agree) to 5 (strongly disagree). These questionnaire items and results are shown in [Table 1]. In addition, an optional open-ended question was asked to saudi medical graduates to express their opinion about their experience, was included in the questionnaire.
Table 1: Main challenges encountered during training

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Data analysis

Data from all returned questionnaires, including those completed partially, were analyzed using the Statistical Package for the Social Sciences (IBM, SPSS version 20, IL, USA). The data analysis included descriptive statistics and proportions to demonstrate the participant's attitude in the four main sections of the questionnaire. Participants' responses to the open-ended question were collected and divided into major themes, for which percentages and frequencies were calculated. Then cross-tabulation was performed for all items pertaining to the main variables. The significance level was set at P < 0.05.


  Results Top


Participant characteristics

Most participants (68.7%) were men. With respect to age, 41.6%, 52.5%, and 5.9% of the respondents were aged between 25 and 29 years, between 30 and 35 years, and 36 years or older, respectively. Furthermore, 76%, 22%, 1%, and 1% of the respondents were married, single, divorced, and cohabiting, respectively. Moreover, 61% of the respondents were parents; 45.9%, 36.1%, 13.1%, and 1.6% had 1, 2, 3, and 5 children, respectively. Participants' demographics are shown in pie [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9].
Figure 1: Distribution of sample members according to gender

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Figure 2: Distribution of sample members according to age

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Figure 3: Distribution of sample members according to their marital status

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Figure 4: Distribution of sample members according to the presence of children

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Figure 5: Distribution of sample members according to number of children

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Figure 6: Distribution of sample members according to their current level of training (residencies or fellowships)

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Figure 7: Distribution of sample members according to number of years in a training program in Saudi Arabia

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Figure 8: Distribution of sample members according to the number of years in the USA before starting the program (including ECFMG certification)

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Figure 9: Distribution of sample members according to number of years in a training program in the USA

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In terms of current training level, the majority of the participants (38.4%) were from postgraduate year level (PGY) 5 and higher, including fellows, followed by PGY 1 (20.9%). A total of 47.5% of the respondents never spent any clinical training in Saudi Arabia, followed by 21.8% who spent 1–2 years in a clinical training program before joining the program in the USA.

Of all the postgraduates represented within the survey, 65% of the students stayed 4 years or less in the USA before starting the program; 65% of the students stayed 4 years or less in the USA before starting the program (including the ECFMG certification ) , 19.5% stayed 3 years, 16.1% stayed 2 years, and 12.6% stayed only 1 year.

Indeed, a high percentage (23.8%) of the students reported spending 1 year in a training program in the USA, and 19% reported spending 2 years, with equal percentages reporting 3 and 5 years.

Challenges encountered during training

Language and communication

Most participants strongly disagreed that lack of English language proficiency was a barrier to learning, misinterpreted as a lack of medical knowledge and skills, and caused them to receive discriminatory comments from their colleagues [Table 2]. The high levels of disagreement regarding receiving discriminatory criticism were common in PGY 5 (R5) and higher levels such as fellows (n = 26, 44.8%; P = 0.097).
Table 2: Participants' responses to questionnaire items concerning attitudes

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Furthermore, most participants who had 1 or 2 children (n = 30, 88.2%; P = 0.039) strongly disagreed that they experienced any difficulty discussing do-not-resuscitate (DNR) orders and end-of-life issues with patients and their families. Postgraduates aged 35 years or younger (n = 49, 94.2%; P = 0.036) who had children (n = 32, 61.5%; P = 0.042) strongly disagreed that they were uncomfortable with patients' psychosocial and emotional issues because of their training and cultural background.

Learning and education

Most participants reported positive experiences involving the learning environment and strongly agreed that their training was relevant to their future practice; this finding was most prominent in the postgraduate male population (78.7%, n = 48; P = 0.023) with 1 or 2 children (85%, n = 34; P = 0.051).

Furthermore, participants reported receiving good support and guidance from their training programs; this finding was most prominent in postgraduate men (75.8%, n = 47; P = 0.051). Moreover, participants reported receiving good support in dealing with patients' psychosocial and emotional issues; this finding was also most prominent in postgraduate men (76.4%, n = 42; P = 0.097) aged 25–35 years (n = 51; 92.7%; P = 0.097).

Furthermore, some participants strongly agreed that they had received fair evaluations at the end of each clinical rotation. Surprisingly, some participants neither agreed nor disagreed that they had been doing more clinical work than receiving teaching.

Social and cultural factors

Most participants strongly agreed that they received good support from people with similar cultural backgrounds; this finding was most prominent in postgraduates aged 25–35 years (n = 44, 95.6%; P = 0.070). Some participants also reported having good relationships with USA citizens.

Almost half of the participants, most of whom were men, did not perceive any type of discriminatory attitudes from faculty members (n = 51, 73.9%; P = 0.002) or nurses (n = 47, 72.3%; P = 0.023). Moreover, some participants reported that they did not find it difficult to perform their religious activities, including wearing a hijab, fasting, and praying.

Administrative issues

Approximately one-third of the participants strongly agreed that they received good support from the postgraduate office in resolving administrative issues; this finding was most prominent in postgraduates aged 25–35 years (n = 45, 93.8%; P = 0.029). Furthermore, some participants, most of whom were men, felt that their rights were protected throughout their training program (n = 37, 77.1%; P = 0.030).

Moreover, most participants reported equal treatment regarding administrative responsibilities and opportunities, and one-third of them felt that their program provided a good mentoring system. This finding was most prominent in married participants (n = 47, 87%; P = 0.040) with 1 or 2 children (n = 31, 88.6%; P = 0.103).

Moreover, the number of men who strongly disagreed that English language proficiency was a barrier in their learning was significantly higher relative to that of women (P = 0.032). However, the number of male residents who strongly agreed that their training was relevant to their future practice (P = 0.007) and supported them in dealing with patients' psychosocial and emotional issues (P = 0.037) was significantly higher than those of women.

Meaningful or challenging experiences during training

The data collected regarding important experiences in which culture, language, or values affected participants' ability to deliver appropriate patient care were categorized into major themes, for which cross-tabulation was performed [Table 2].

Main challenges identified in cross-tabulation

Other challenges

Other challenges reported by participants included a lack of guidance in the training experience, writing in patients' charts, typing fast using a keyboard, using electronic medical records, and constant comparison with graduates from the USA. These obstacles were most prominent in postgraduates who had spent up to 8 years abroad (n = 12; P = 0.041) and had 1 or 2 children (n = 5, 83.3%; P = 0.036).

Religious difficulties

Religious difficulties constituted more obstacles for postgraduates who had spent up to 4 years in a training program abroad, relative to those reported by other participants (P = 0.001). These obstacles included difficulties in performing religious duties because of heavy workloads and long rounds, wearing a hijab, fasting, and unpleasant comments. For example, one participant stated, “They said [that] I am a restricted woman because I am fasting during Ramadan.”

Learning and education

During the learning and education process, some SMGs experienced being passed over for additional positions in residency or fellowship programs and squeezed into the schedule, which affected their training experience.

Others, somehow, learned in their programs that the training involves only practical duties and that learning and studying is an individual's responsibility for which they should block out their schedule, which can hamper their background knowledge as well as preparation for subspecialty (i.e., fellowship) application.

Social and cultural factors

Participants faced numerous social obstacles, including adaptation to a new culture, treating alcoholic or addicted patients, understanding of patient privacy and the care delivery process, difficulties in booking vacations, facing poor understanding of and sarcastic comments about Saudi culture, being made to feel uncomfortable or that they were wasting time being taught, and responsibilities toward their families as mothers. The proportion of women (80%) who faced these obstacles was significantly higher than that of men (P = 0.016).

One member expressed that his residency program did not permit him to have over 2 days' vacation in a row. Another member stated that the staff did not care for the possibility that he was a Saudi doctor, and they continued saying that women do not drive and they do not go to class.

Do-not-resuscitate orders and end-of-life care

SMGs who had stayed abroad for at least 8 years or been enrolled in a training program abroad for at least 3 years reported more significant difficulties related to DNR orders and end-of-life issues relative to those reported by other SMGs (P < 0.001).

Nevertheless, some participants reported positive experiences involving end-of-life care. They received understanding and cooperation from their teams, allowing them to relinquish responsibility for the care of patients with no repercussions. For example, one participant stated, “I was asked one time to administer medication, which was futile; I explained to my attending and the team that it was against my beliefs, and they were understanding.”

Language and communication

The proportion of single SMGs who reported difficulties in their spoken or written language and communication skills (66.7%) was higher than that of married participants (P = 0.058). One participant stated, “I felt that the most difficult period was the first few months, and it was mainly because of the language barrier.”

None

The proportion of postgraduates aged 30 years or older who reported that they had not encountered any difficulties throughout their entire training experience was higher than that of other participants (n = 3, 20.5%; P = 0.070).

Visa acquisition

Two postgraduates who had spent at least 5 years in residency training in Saudi Arabia and two female postgraduates experienced difficulties in obtaining visas for themselves (P < 0.001) or their spouses (P < 0.034), which could have affected them psychologically and created further social, employment, and health difficulties, as shown in the participant's statement below.

  • My husband was supposed to start with me in June 2013, but due to delays and visa issues, we separated for eight months, which affected my performance.


The SACM

One of the participants reported problems related to the SACM, as they discontinued her monthly allowance when her training was terminated instead of helping her.


  Discussion Top


Our study provided a unique review of difficulties and the broad spectrum of challenges faced by SMGs. These challenges included the language barrier, difficulty in learning, social factors, cultural adaptation, and administrative issues. Therefore, we separated the results of the study into the following four main sections:

Language and communication

Language is an essential tool for effective communication and establishing a good rapport between patients and treating physicians. As IMGs came from countries where English is not the native language, they lacked proficiency.[12] A study conducted by Hall et al., which included more than 70% of the SMGs, reported a high level of agreement between all parties involved, indicating that they had specific educational needs involving communication skills and training issues related to health-care system.[19]

In contrast, most participants in this current study did not perceive discrimination related to their language proficiency, and they were reluctant to consider English language weakness a barrier to the learning process, a reason for lack of medical knowledge and skills, or a cause of stress when interviewing patients and communicating with health professionals. This disagreement is because the English language is considered the second spoken language in Saudi Arabia since it is mandatory to study the English language in Saudi schools. Furthermore, SMGs must pass the English language proficiency examination, either TOEFL or IELTS, with high grades to apply for most residency or fellowship training programs in the USA. This examination preparation includes courses attending with numerous efforts to obtain high grades in the examination sections involving reading, listening, speaking, and writing sections. However, this was consistent with some previous studies in which IMGs reported not considering their accents a significant barrier or significant issue. Moreover, one study reported that the language barrier was a minor obstacle, mainly because English was used in education at participants' native medical schools.[20]

Social and cultural factors

In adapting to a new culture, IMGs pass through three psychological stages: feelings of personal and professional loss, followed by disorientation, and culminate in adaptation to the culture via the development of multiple coping strategies. This adaptation could be facilitated by the receipt of support from other IMGs and colleagues.[21] Our data show that IMGs received support from other IMGs and maintained good relationships with US citizens.

Furthermore, some previous studies have revealed the presence of social barriers involving DNR order discussion and bad news disclosure.[22] In contrast, the participants in the current study were comfortable with the patient's psychosocial issues. They did not report any obstacles in discussing DNR or end-of-life issues with the patients and their families or performing any religious activities. Our participant's response was mainly because of the US medical team's understanding of SMGs' beliefs. They were cooperative in allowing them not to discuss end-of-life issues with patient families if they requested so, as our respondents provided. Furthermore, our participants did not perceive any discriminatory attitudes from faculty members or nurses.

Administrative issues

Discrimination against IMGs occurred through inequality, whereby IMGs' colleagues were favored concerning opportunities involving administrative positions, seniority, and promotion.[23] Furthermore, IMGs have issues regarding contract signing and obtaining new positions compared to the US medical graduates, which affects their career satisfaction.[24] Furthermore, IMGs reported that they feel that they face discrimination in which Other US graduates take chief positions, and they do not take higher or leadership positions in their career in comparison to the US gradates.[25]

Our study findings suggested that there was no discrimination involving administrative responsibilities between IMGs and their colleagues. This agreement could be related to SMGs going back to Saudi Arabia after they finish their residency or fellowship training, so they do not have to compete with US graduates in the positions. Furthermore, some US postgraduate programs' regulation is to treat all residents and fellows in similar ways.

Consistent with our results, some studies have reported equality in membership rights and opportunities to achieve a high academic ranking for IMGs and their peers.[26] Furthermore, some programs reported that IMGs have success at the programs with the ability to obtain high grades in the board examinations, obtain very well-known fellowships, and important positions as staff.[27]

Learning and education

The results showed that most participants were satisfied with their training. Indeed, they considered their training fair and relevant to their future practice and indicated that the training programs provided them with support and guidance and taught them how to deal with patients' emotional issues. Although they did not report any difficulties or perceive any education-related discrimination, some participants were hesitant to spend more time being taught rather than performing clinical work. In congruence with our findings, some studies demonstrated IMGs' ability to occupy important positions, which American medical graduates did not hold during training.[26] For example, a retrospective study concluded that IMGs held more advanced academic degrees, produced an enormous amount of academic work, and held more jobs in research or surgery following graduation relative to graduates from the USA.[28]

In contrast to the current findings, one study reported that IMGs experienced discrimination in the form of limited practice options, insufficient opportunities for assessment, financial barriers to training, and barriers to licensing for practice.[29] For example, some programs consider IMGs to be problem residents[30] even though they exhibit similar clinical skills and examination grades to native medical graduates.[10] Furthermore, some programs could consider IMGs an extra educational burden for residency programs in the USA,[31] which highlights the need for good mentoring and supportive programs for IMGs, to facilitate their integration into the health-care system.[32]

Limitation of the study

Our study has some limitations since it only includes 1 year and excluded nurses, physiotherapists, and other health-care professionals' experiences in the health-care environment. Furthermore, we excluded SMGs who were preparing for USMLE examinations in the USA and who were doing electives or observerships in American hospitals.

Implications for training

Our study can provide data to create unique training programs to facilitate the integration of SMGs into American residency and fellowship training programs. Furthermore, it helps SMGs to understand the challenges they might face during their residency and fellowship training programs in the USA, which mainly relate to language proficiency, learning objectives, social barriers, and administration opportunities.


  Conclusions Top


The results of the study are significant and suggest that the SMGs who participated in the study had pleasant experiences and faced negligible barriers while studying in the USA. However, subgroup analysis showed that women's experiences were less positive relative to those observed in men. Nevertheless, efforts should be made to implement policies and strategies that strengthen the role of the SACM to improve training objectives.

Main messages

  • Saudi IMGs had an overall positive experience while studying in the United States of America
  • Saudi IMG women appear to have more challenges in comparison to men
  • No difficulties were encountered during residency and fellowship training regarding language, learning, social, and cultural factors.


Research questions

What steps are needed for the proper integration of Saudi IMGs into the USA health-care system?

  • What are the primary learning responsibilities required by Saudi IMGs as residents or fellows?
  • What interventions are most effective for Saudi IMGs' adaptation to a new culture?


Acknowledgments

We would like to thank the Saudi IMGs who participated in this research and the SACM for kindly providing us with the Saudi resident and fellow list.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
 
 
    Tables

  [Table 1], [Table 2]



 

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  In this article
Abstract
Introduction
Materials and Me...
Results
Discussion
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