CSA RESOURCES SPECIALLY FOR INTERNATIONAL MEDICAL GRADUATES.

Some trainees attend CSA courses and get told (in their feedback) that they need to be ‘more British’. Personally, I think it’s an awful phrase because

1. It is vague and therefore can mean different things to different people.  For example, is spending two weeks in a European mass tourist holiday destination, getting sunburnt, drinking too much, slurring unintelligible football chants and taking all sorts of risks with one’s sexual health the essence of being British? Or is it tut tutting at such behavior through the pages of a popular newspaper? (Hopefully, you’ll say neither).
2. It doesn’t celebrate the cultural diversity and individuality inherent within our IMGs – which we all can use and learn from.  Actually, Damian Green (the UK’s immigration officer) recently said that ‘to be British is to be part of a ‘tolerant and mutually respectful society’.
3. It might give the impression to others that being ‘British’ implies a sense of a more superior culture, which is clearly not the intention (nor the reality) when trainees are being advised to be more ‘British’.

I think what people mean when they advise their trainees that they need to be ‘more British’ is that they need to develop their linguistic capital in their internal linguistic bank.

So let’s go onto define what that exactly means.  Linguistic capital (Bourdieu, 1990) is defined as the mastery of and relation to language. And that doesn’t just mean having a good vocabulary. Other than fluency, we are talking about the expertise and comfort with a language – idioms, turns of phrase and so on.

Trainees can expand their linguistic capital if they submerge themselves in British culture through watching soap operas, widening their social circle of friends and going out with English groups.

The idea is that by being immersed in UK idioms, turns of phrase, meta-communication, tone of voice etc., one understands them better and might even start to use them.

If IMGs make no attempt to get a grasp of these things, they then remain culturally alien to them. This in turn will affect their learning, growth and thus other people’s (e.g. patients’) faith in them.

Investing in linguistic capital is a long term endeavour and that the returns are seldom immediate.

By having good linguistic capital of a culture that is not part of your embodied* cultural capitol (i.e. from the country you were brough up in) can give you three good advantages in your host country:

1. It gives you a means of being able to communicate effectively with others (like patients)
2. It gives others some sort of faith, respect and reliance in you.  It’s like presenting yourself and showing that you’ve submerged yourself in your surrounding culture and have acquired a lot from it – and people respect you for that no matter what country you’re in.
3. Linguistic capital thesis states that trainees who possess, or develop linguistic capital, thereby have access to better life chances.

Remember, linguistic capital can be acquired even by those who do not have ancestral precedents.

For example, it is completely possible for a Tamil trainee who still lives with his Tamil speaking parents to acquire linguistic capital that is grounded in English.

* Embodied cultural capital = consists of both the consciously acquired and the passively “inherited” properties of one’s self (with “inherit[ance]” here used not in the genetic sense but in the sense of receipt over time, usually from the family through socialisation, of culture and traditions). Cultural capital is not transmissible instantaneously like a gift or bequest; rather, it is acquired over time as it impresses itself upon one’s habitus (character and way of thinking), which in turn becomes more attentive to or primed to receive similar influences.

• Start watch English TV soaps (and talk about episodes with some of your reception staff, admin staff, colleagues and British born friends).
• Start making new friends – don’t just stick with other people who are also IMGs (otherwise you may learn some grossly wrong habits). Try and make some British-born friends too. Go out for a coffee, beer, meal…. anything – just socialise and engage in banter!
• Try starting to talking at home in English.
• Take an interest in novels written in English – especially if they’re based in the UK.  You may understand UK society better.

The problems with consulting skills seem to follow a similar pattern, with a lack of listening particularly in the early part of the consultation and as a result, jumping to premature conclusions about the nature of the problem.  Nick Whelan has a useful analogy that ‘ you can’t cross the road from halfway across; to do it well or to survive the crossing, you have to get it right at the start’.

Going on a one off CSA course is not necessarily going to make it all better for you – get out of this bad way of thinking that the answer to everything is a course!

What you need is continuous, consistent and persistent targeted training with repeated practise on substantial issues like communication skills. 

Half days are often not thought to allow sufficient time for deep learning to be supported. Even with full days, you must continue to PRACTISE those skills in your everyday working life.

Try and view the courses you attend as platforms that allow you to move off to a higher level.

Stop seeing them as quick fixes.

• Get to know and like your trainee.   Otherwise, that altruistic nature of wanting to help them might fade and disappear.
• Use the RDM-p framework to help ‘diagnose’ what the current difficulties are for your IMG trainee. RDM-p framework available here.
• Start any remediation work EARLY. If your trainee is at the ST1 stage – start and do it there! The earlier, the better. Don’t just think someone else will pick it all up and fix it later. You need to start that fixing process early, right now! (Likewise for Educational Supervisors who may notice ‘things’ whilst the trainee is in a hospital post). We have to act before trainees begin to fail – otherwise resources are wasted and all stakeholders suffer.  And we owe it to our trainees to give them the best opportunity for success and development.
• It can be difficult to judge the extent to which to educate IMG’s separately from their UK trained peers. There are potential risks of stigmatisation and emphasising differences that must be avoided. The experience is that IMG’s appreciate the insight of educators into their difficulties and their support in overcoming specific challenges. Peer education is a powerful, and finding opportunities for additional educational activities for doctors with a heavy service commitment can be challenging.
• Thank you sooooo much, Dr Mehay. We all love you for what you are doing… Awesome!