Title: ‘Hiding in Plain Sight’: A Qualitative Study of International Medical Graduates Returning to Their Home Country for Internal Medicine Residency

Title: ‘Hiding in Plain Sight’: A Qualitative Study of International Medical Graduates Returning to Their Home Country for Internal Medicine Residency | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Title: ‘Hiding in Plain Sight’: A Qualitative Study of International Medical Graduates Returning to Their Home Country for Internal Medicine Residency Zahra Merali, Kristen A Bishop, Jacqueline Torti, Mark Goldszmidt This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8585367/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background International Medical Graduates (IMGs) comprise a large share of the global medical workforce and often face challenges integrating into residency, even when returning to their country of citizenship. These needs remain poorly understood, limiting programs’ ability to provide targeted support. In Canada, such physicians—Canadian citizens trained abroad (Canadian-IMGs) encounter similar barriers in Internal Medicine (IM) residency. The purpose of this study was to explore the integration experiences of IM C-IMGs. Methods Using constructivist grounded theory, we conducted semi-structured interviews with IM Canadian-IMGs and program directors/faculty across Canada. Consistent with our methodology, we used constant comparison and iterative cycles of data collection and analysis. Data were collected until theoretical sufficiency was achieved. Results Nineteen participants were interviewed between January 2023 and April 2024: 12 Canadian-IMGs and seven faculty. A hallmark finding was a perceived need by participant Canadian-IMGs to ‘hide in plain sight’ and keep their training background hidden, at the sacrifice of requesting support. Participants also described a ‘critical period of growth’, that Canadian-IMGs navigated when starting residency, characterized by the early personal recognition of a gap between their strong theoretical but minimal practical knowledge. As a result, some resident participants also described a ‘lingering effect’ of self-doubt that persisted well beyond first year. Conclusion While focused on the Canadian context, this study adds novel insights into the experiences of citizens who study abroad and return to their own country for residency training. In particular, some residents intentionally hid their IMG status, but this came at a cost, often with long-term consequences. We identified several strategies to visibly acknowledge their journey and offer supports such as through authentic mentorship. Findings may inform international programs with IMGs who have returned to their home countries for postgraduate training. International medical graduates postgraduate education Canada Internal medicine qualitative research imposter syndrome Figures Figure 1 Background The transition into residency in one’s home country after attending medical training abroad is challenging for medical trainees internationally ( 1 – 4 ). International medical graduates (IMGs)- physicians who practice medicine in a country different from where they were trained- comprise a substantial proportion of the medical workforce globally, including over 40% in Australia, Ireland, Israel, New Zealand and Norway, 40% in the United Kingdom and 25% of practicing doctors in North America ( 5 ). IMGs struggle with integration into their postgraduate training programs, even those who are citizens in their home country ( 6 , 7 ). Challenges include perceived discrimination ( 7 – 12 ), self-doubt ( 13 ) and difficulties with orienting and transitioning to residency ( 7 , 14 ). Within the IMG population, important distinctions exist between immigrants with a medical degree from another country (I-IMGs) and citizens who studied abroad and return home for postgraduate training ( 4 , 15 ). Despite the growing prevalence of citizens pursuing medical education abroad internationally ( 3 , 16 , 17 ), most studies on IMG integration in residency do not differentiate between these subgroups ( 3 , 6 , 9 , 10 , 12 ), leaving the experiences of returning citizens poorly understood. The few studies that do differentiate between IMG types are based in Canada and separate IMGs into I-IMGs and Canadian citizens who have studied abroad (C-IMGs) ( 7 , 8 , 14 , 15 , 18 ). These studies reveal important differences: while I-IMGs- some of whom have practiced medicine prior to immigrating ( 7 )- highlight cultural transition and communication barriers as specific challenges, C-IMGs report different struggles, including adapting to clinical responsibilities, overnight call expectations and other nuances of the healthcare system navigation ( 7 , 14 , 18 ). Further distinguishing C-IMGs are their ability to “blend in” with their Canadian graduate peers ( 7 , 14 ). The fact that they are IMGs can, at times, be unknown to their supervisors, leaving them to struggle with critical competencies without necessary supports ( 7 , 15 ). Most program supports for IMGs focus on the cultural transition to residency ( 9 , 15 ), which C-IMGs perceive as largely irrelevant to their needs ( 7 ). Few studies have attempted to understand the unique challenges that C-IMGs face ( 7 , 14 , 15 , 18 , 19 ), and even fewer are focused on specialities such as Internal Medicine (IM) ( 7 , 9 , 14 ), where C-IMGs represent approximately 11% of residents ( 20 ). Understanding these experiences is essential for developing adequate interventions and program supports that are tailored to meet their unique needs. The purpose of this study was to explore the integration experiences of IM C-IMGs, as perceived by themselves and those around them. In doing so, we hoped to gain novel insights into how best to support IM C-IMGs as they transition into and through their residency programs. While this study focuses on the Canadian context, our findings may inform programs in other countries facing similar workforce dynamics ( 4 , 5 , 18 ). Methods Study Design A constructivist grounded theory approach was chosen because it is ideal for studying complex social phenomena where theory development could help provide novel insights– in this case, novel insights into the experiences of C-IMGs in IM residency ( 21 ). We interviewed IM C-IMG residents with shared yet distinct experiences in Canadian residency programs and program directors or designated faculty (defined as attendings who have a leadership role in training C-IMGs, as identified by the program director). We selected C-IMG residents who had completed at least one year of post-graduate training, given that their first-hand experience and opportunity to reflect positioned them as an ideal group to offer insights into personal education and program needs. Program directors (or designated faculty) often oversee the experience of C-IMGs and are responsible for program development and refinement, making their perspectives also important. IM was chosen as the specialty program of interest given the high clinical responsibility, the residency demands and the paucity of literature in this area ( 7 , 15 , 22 ). Recruitment was completed through email via program administrators from the 14 IM programs in Canada that accepted C-IMGs at the time of study (University of Ottawa, Queen’s University, University of Toronto, McMaster University, Western University, University of Manitoba, University of Saskatchewan, University of Alberta, University of Calgary, University of British Columbia, Université Laval, Université de Sherbrooke, Université Montreal, McGill University), social media, and snowball sampling ( 23 ) after the initial interviews. Virtual semi-structured individual interviews and focus groups (to accommodate participants located across Canada) were conducted with post-graduate year (PGY)-2 to PGY-6 IM residents and program directors (or designated faculty) across Canada. This study was approved by the Western University Research Ethics Board. Data Collection and Analysis Prior to each interview, informed consent was obtained. A total of 17 individual interviews and two focus groups (including three to four participants each) were conducted by Z.M. The interviews ranged from 40–72 minutes (average 56 minutes). Our interview guide was revised iteratively as we gained new insights through each interview [Appendix A, Appendix B]. Consistent with constructivist grounded theory, data collection and analysis took place iteratively ( 21 ). The first five transcripts were selected for open coding. Coding was supported by NVivo software, version 12 (QSR International). Transcripts were de-identified by Z.M. and read recursively by Z.M., M.G., and K.A.B. and then reviewed across a series of meetings, leading to the creation of a set of focused codes. Challenges or uncertainties encountered during coding were resolved through discussions at regular research team meetings. To support rigour, constant comparison was also used; as new insights emerged, new codes were added and definitions for focused codes were updated. All previously coded transcripts were then re-read and re-coded. Constant comparison was also used as we identified thematic categories across our codes and tried to understand their relationship to each other, which helped us develop our theory ( 21 ). For the purpose of clarification and refinement of key concepts, the developed theory was then presented during further focus groups or individual semi-structured interviews with a subgroup of existing and new participants as a form of member checking. Data collection and analysis ceased when members of the research team felt that further sampling would provide no greater insight into the theoretical model, also known as theoretical sufficiency ( 24 ). Rigour was further supported through reflexive memo-ing [Appendix C] and investigator triangulation ( 21 ). Reflexivity Z.M. is an early-career IM physician who is a C-IMG herself. This was a very personal study, and being an insider was helpful during the interviews as it allowed Z.M. to engage meaningfully in what were often shared experiences with resident participants. The research team also consisted of M.G. (PhD education researcher and an experienced IM attending physician who supervises C-IMGs) and two non-clinician PhD medical education researchers (K.A.B. and J.T.) who helped to challenge the primary author’s assumptions and experiences through frequent meetings. As part of regular reflexive dialogue, Z.M. was asked questions such as “Was this true to you or true to the data?” These conversations helped to enhance the richness of our analysis ( 25 ). Since the data collection, Z.M has had the opportunity to augment her own experience as a C-IMG and the experiences from those she interviewed, which has helped her provide meaningful mentorship to C-IMGs she supervises in her practice. Study Context In Canada, IM residency is four years with the option to subspecialize in postgraduate years four and five. During training, residents rotate between the IM inpatient teaching service, frequently called the clinical teaching unit (CTU), and other subspeciality services such as Cardiology, Gastroenterology and Critical Care ( 22 ). Canadian medical students in their core rotations (six to eight weeks) are expected to take responsibility for patient care on the CTU with graduated supervision by senior team members ( 14 , 26 ). Likewise, in the United States, many undergraduate programs offer an IM “sub-internship,” for students to serve as acting interns with similar expectations for a four-week rotation ( 27 ). In contrast, in several European countries, such as Ireland, medical students see several different patients and are expected to present structured histories and examination findings for practice, followed by questions from their attendings about the pathophysiology and management of relevant conditions, but their presentations rarely inform decisions around patient care. Patient care responsibilities are delayed until intern year ( 14 , 17 ). Results In total, 19 participants from IM programs across Canada were interviewed between January 2023 and April 2024 [Table 1]. As depicted in Figure 1, our main study finding relates to the experience of both wanting and being able to hide in plain sight which, at times, was to their own detriment. For some, it started pre-residency when hearing about other C-IMGs and the stigma they experienced during their transitions to residency. It could also be developed and reinforced early on during their own transitions. Although participants felt they had strong theoretical knowledge, their patient care experiences from undergraduate training were mostly observational leading to a critical period of growth during which they had to catch up to their Canadian graduate peers. Moreover, over time, even with objective evidence that they had caught up, many described a lingering effect of self-doubt and inadequacy. In the following sections, we will describe each of these aspects in more detail and share participant perspectives on ways to improve the C-IMG early residency experience to diminish the feeling of needing to hide. Quotations from residents are represented by “Pr” (Pr1-12) and program directors or designated faculty (hereafter referred to as attendings) are represented by “Pa” (Pa13-19).” Table 1. Demographic Details C-IMG Participants Total 12 Program Directors or Designated Faculty Total 7 Gender Post-graduate Year (PGY) Gender Female 10 PGY2-3s 4 Female 4 Male 2 PGY4-6s 8 Male 3 Undergraduate Country Post-graduate Program University* Post-graduate Program Region* N Ireland 6 McMaster University 7 Ontario 4 Australia 2 University of Manitoba 2 Western Canada 3 Poland 2 University of Ottawa 2 United Kingdom 1 Western University 1 New Zealand 1 Abbreviations: C-IMG= Canadian-International Medical Graduates Note: Further demographic details for all participants are withheld to protect anonymity. *Only post-graduate programs that accept IMGs were included in recruitment: University of Ottawa, Queen’s University, University of Toronto, McMaster University, University of Manitoba, University of Saskatchewan, University of Alberta, Western University, University of Calgary, University of British Columbia, Université Laval, Université de Sherbrooke, Université Montreal, McGill University Figure 1. Hiding in Plain Sight Abbreviations: C-IMG= Canadian-International Medical Graduate Image created on: Canva.com Alt Text: Figure showing the “Hiding in Plain Sight” concept: an iceberg diagram illustrating visible and hidden aspects of Canadian-International Medical Graduate experiences during the transition to residency Hiding in Plain Sight “As a new resident, I don't want a big halo on my head like a character in a video game that says, I'm an IMG…I want to blend in and…be one of the of ‘the boys’…without being different” (Pr1). As described by C-IMG Participant 1 in [Table 2], many C-IMG participants expressed a desire to hide their training status in early residency because of the perceived stigma of being a C-IMG. They were often successful in doing so because growing up in Canada, they ‘fit in’ culturally. [Table 2 here] C-IMG and attending participants expressed how “C-IMGs…may be [perceived as] less clinically strong than [Canadian graduates]” (Pr2). A few C-IMG participants highlighted that they were aware of this perception of a “negative tone around C-IMGs” (Pr5) while still in medical school through colleagues who had already returned to the Canadian system as C-IMGs. Several C-IMGs also indicated that this perception was reinforced during residency, leading many C-IMG participants to “ want to blend in ” (Pr1) and hide their status of being other. This, in some cases – as further elaborated in the sections below – permeated their actions during their critical period of growth by changing the way they sought help from others (if at all) and impacted their relationships with their peers. This perceived need to hide also compounded the emotional toll of early residency, and the ability or willingness to disclose their struggles to potential sources of support. Some C-IMG participants, such as Participant 4 in [Table 3], described that during this challenging timeframe they experienced relief at a moment of unmasking, or open, authentic acknowledgement of their C-IMG status. In this case, it was a conversation initiated by their attending where they “ validated my feelings ” by describing they knew other IMGs who “ also cried during their first summer ” and were now “ excellent physicians ” (Table 3, Row 2, Column 3, Pr4). [Table 3 here] Critical Period of Growth and Catching Up As shown in Table 2, due to differences in their undergraduate training , the first year of residency was a critical period of growth where participants felt they needed to catch up to their Canadian graduate peers. While the catch up period was concentrated in the first two months of residency, participants varied in their descriptions of it lasting between “a few months” (Pr2, Pa13, Pa14, Pa15), “by month 3-4” (Pr4, Pr5, Pr7, Pa18) and “the first 6-12 months” (Pr1, Pr3, Pr6, Pr8-12, Pa16, Pa17, Pa19), during which they gained knowledge about institution specific processes, clinical knowledge, abstract reasoning skills and subsequently, comfort and confidence. Participants could not identify specific resources that helped them catch up , but rather described the importance of experiential learning: “…it’s just a matter of time and experience” (Pr1); another described: “getting a lot of clinical experience really quickly upfront…I guess you kind of sink or swim, right, and you just get that experience and you move forward” (Pr2). In terms of explaining why this happened, when discussing the difference between the C-IMG undergraduate experience compared to that of Canadian graduates, many C-IMG participants described their prior training as: “ more of an observership …” (Table 2, Pr12) , or, theoretical – focused on book knowledge, clinical skills and physical exams without the chance to apply theoretical knowledge in practice. In contrast, participants flagged how Canadian medical students act in a clerkship or intern role, where, in a graduated fashion, they are responsible for the direct care of a select number of patients on their team. Due to this difference in training, unlike C-IMGs, Canadian medical students had the chance to become familiar with how to function effectively on their IM rotation. Participant C-IMGs described being in a phase of disorientation , where they were burdened with “the stress of the unknown” (Pr4), whichcreated a sense of feeling “lost” (Pr5, Pr6) and not knowing “ how to do anything …” (Table 2, Pr3). Other C-IMG participants highlighted that there was a lack of awareness of their expectations as a first-year resident. For example, one resident participant described the experience on their first day, splitting the list in the morning, going off to see their own patients, and feeling “ [shocked and intimidated] that I was rounding on all my patients [alone]” not realizing that the senior resident and attending would also be seeing the patient “ in the background” (Pr2). Further, C-IMGs felt that when it came to making clinical decisions , they theoretically knew how to treat different disease patterns, but unlike their Canadian graduate peers, they couldn’t articulate “the exact steps” (Table 2, Pr7) to treat their patients. Both C-IMG and attending participants noted their experiences and performance gaps were separate from I-IMGs. One participant, when comparing themselves to I-IMGs, described that I-IMGs had significant experience “under their belt in terms of practice and knowledge,” and they themselves “wished I had that experience going into residency,” instead feeling like “the least experienced person on the team despite being born in Canada” (Pr4). Throughout this initial period, the C-IMGs perceived need to hide impacted relationships with their peers, their educational opportunities in early residency and their experiences receiving feedback from attendings. When questions arose on the wards, some C-IMG participants felt “ all my [Canadian graduate peers] already know this… ” (Table 2, Pr8) and therefore would ask C-IMG peers for help and form friendships with C-IMGs more easily than Canadian graduates. They also struggled to balance their need to keep their status hidden while also engaging in support and learning opportunities. In some cases, when faced with an acute case, they asked for help prematurely , “ escalated it…right away…” (Table 2, Pr2) before starting any initial management. In others, they delayed seeking help , as they felt they should “ figure it out on my own” (Table 2, Pr8). A few C-IMG participants had completed an intern year at their international undergraduate country prior to IM residency in Canada. These participants, unlike the other C-IMGs interviewed, felt comfortable with night-time duties, like holding a pager or taking care of acutely unwell patients with limited support. However, even for them, team rounding, and hierarchical patient care decisions were more common in their international hospitals. Thus, daytime expectations, such as independently forming management plans, were a challenge for these residents because prior to their Canadian residency, they had “ never [been] making a decision by [themselves] and [were] never going and assessing a patient really by [themselves] during the day…” (Table 2, Pr10) . Emotional Toll & Its Lingering Effect “I just burst into tears…” (Table 2, Pr5), is one example of many vivid descriptions of the emotional toll C-IMGs had in their transition through residency. When discussing their initial experiences in residency all C-IMG participants revealed several negative emotions such as feeling “ s tressed” (Pr1, Pr3, Pr4, Pr5, Pr7, Pr12), “ overwhelmed” (Pr2, Pr3, Pr4, Pr7, Pr8, Pr9, Pr11, Pr12), “ anxious” (Pr4, Pr8), “ scared” (Pr6, Pr10) and “stupid and behind” (Pr12). Some C-IMG participants felt their perceived need to hide prevented them from openly speaking of their emotions, even with their mentors: “We did have an academic advisor…they follow us for our [interim assessments], and we can talk to them about anything we need to…but I didn’t feel like I could really [talk to them]. And my formal feedback was that things were going fine…” The C-IMG participant expressed that they didn’t want to bring up their C-IMG challenges to avoid “further revealing to them that I was different” (Pr8). This attending encounter is discrepant from the aforementioned quote from Participant 4, who described a moment of relief when an attending initiated a conversation about their C-IMG status and “ validated ” their “ feelings, ” thus, unmasking their perceived hidden status (Table 3, Row 2, Column 3, Pr4). While all C-IMG participants agreed there was a catch up period, many endorsed that their individual experiences navigating the critical period of growth, and its emotional toll had a lingering effect : “ Now I feel on par…But it's taken years to get here. I never felt on par in residency…” (Table 2, Pa17) . This lingering effect of self-doubt, inadequacy, and a need to prove themselves lasted beyond this period and coloured the rest of their training journey. In some cases, this manifested as a skewed frame of reference , especially when facing challenging situations, where participants took on failures as their own “personal flaw…” (Table 2, Pr8) linked to their identity as a C-IMG, even for situations where any trainee –including Canadian graduates – would find challenging. How to Support C-IMGs in IM Residency Both attendings and C-IMGs spoke to the strengths that C-IMGs bring to Canadian postgraduate programs. In particular, their challenging journeys to and through medical school, including their experiences trying to obtain a highly sought-after residency position in Canada, led them to feel privileged and motivated to have a strong work ethic and to “give back” (Pa19) to their programs. Attendings also placed “tremendous value” on the “diverse perspectives” (Pa16) that C-IMGs can contribute. While acknowledging the value that C-IMGs bring to Canadian programs, all participants also felt that more could be done to support them and prevent the perceived need to hide. While unmasking is not without risk, it was felt to be important. Several C-IMGs explicitly described relief when their training status was unmasked or openly acknowledged. However, all felt that it needed to be done in a purposeful way. Attending Participant 17 outlined their strategy with C-IMGs- sitting them down and acknowledging their journey “ I know you’re smart and you’ve studied for your Canadian exams… ”, their current gaps “ your patient management skills are going to be lagging…and that’s ok… ”, and a roadmap of the next few months- “ the goal is by six months you are in step with your average Canadian graduate ” (Table 3, Row 2, Column 3, Pa17). A few C-IMG participants in our return of findings had discrepant experiences when shown hiding in plain sight. These participants still resonated with the internalized perception of a stigma prior to entering residency, however, they had positive and re-enforcing experiences of attending support in their residencies from the beginning, and thus, did not experience a need to hide their status or feel that their learning opportunities were impacted. Resident Participant 10 described their program director setting the tone on their first day of residency, which helped diminish perceived stigma: “She was very, very encouraging...I can remember her saying things like, being an IMG is an asset, you're some of our strongest residents…now that you're in the program, there is no IMG or [Canadian graduates], now we're all [name of University] residents” (Pr10, return of findings focus group). Both C-IMG and attending participants had several ideas about how to create an ideal “environment for success” (Pa16) for C-IMGs. As described in the above sections , C-IMG participants highlighted that their needs were different from I-IMGs, and thus, programs should have dedicated interventions for their cohort. As summarized in [Table 3] Columns 1 and 2, participants identified several interventions that can be instituted pre-residency and during residency to help support C-IMGs. Discussion Despite the number of trainees globally who pursue medical education abroad and return to their home countries for postgraduate training, little is known about their unique integration experiences and support needs (7, 16, 18). The purpose of this study was to explore one such group, IM C-IMGs and their integration experiences, to gain insights into ways to improve their transition back to residency programs in their home country. Building on prior research, our study identifies experiences unique to this group of IMGs (7, 14, 15). More compelling, however, were new insights around the perceived need, for many to hide in plain sight and the impact of this in relation to the common experiences of the critical period of growth and its long-term consequences. Our findings also contribute ways to better support them in their residency journeys. Although our study is specific to the Canadian context, lessons learned can inform international programs that accept trainees who return to their home country for postgraduate training. Throughout the residency experience, nearly every participant described a critical period of growth that C-IMGs had to endure until they had caught up with their Canadian graduate peers. During this, their struggles and associated negative feelings were largely hidden from others. Perceived stigmatization and a desire to “blend in” with peers have been described by IMGs and other minoritized groups in residency (7, 28-30). What distinguishes the C-IMG experience is that, in many cases, they are able to successfully do so, sometimes at the expense of receiving support and engaging in learning opportunities (15). Social identity theory suggests that individuals derive their self-concept from group membership, with different identities becoming salient depending on context (31, 32). Members of marginalized groups may suppress or conceal aspects of their identity to navigate dominant workplace cultures (32, 33). Retrospectively, this framework is relevant when considering our findings: C-IMGs share national identity with Canadian graduate peers but differ in educational pathways, creating tension around which identity is more salient (16, 32). To resolve this tension and to belong to the in-group, some C-IMGs tried to conceal their IMG identity (16, 31). It is not surprising that this concealment at a time when the C-IMGs described they were struggling, led to lingering effects -including feelings resembling impostor syndrome- that persisted for years and may have prolonged or disrupted identity formation (28, 32, 34, 35). If, as we believe, this experience is shared by many C-IMGs, there is a pressing need to change how we support C-IMGs from undergraduate to postgraduate training. Key to the creation of -what one participant coined- “ an environment for success” to diminish the C-IMGs’ perceived need to hide is authentic mentorship (Table 3, Row 3) (36). This could reduce stigmatization and allow for open acknowledgement of the C-IMG training status and unique journey. However, implementing this both sensitively and meaningfully would require significant faculty development to help supervisors better understand the C-IMG experience and have strategies for exploring this with their C-IMG trainees in an individualized way. It would also require setting up, especially in early residency, check-ins between faculty and C-IMGs to allow for this to unfold in supportive ways with, as necessary, the discussion of tools and strategies (7, 19). Another identified strategy that is supported by prior research would be vertical near peer mentorship programs (7), which can be a place where residents feel safe asking questions and feel validated that their experience is one that others have also been through. If successful, this could help foster an environment where C-IMGs feel supported and valued, diminish the need to hide, shorten the time it takes to catch up with their peers, and mitigate emotional consequences. Beyond mentorship, participants also suggested other program-level recommendations that could potentially soften the emotional toll of the critical period of growth that C-IMGs experience (Table 3, Column 3) . Although many participants described the importance of orientation bootcamps and clinical skills workshops (7, 9), they also emphasized intentional and mindful scheduling by programs. Consistent with prior research (7, 15), all participants advocated against assigning C-IMG overnight call duties before they had received adequate daytime orientation to clinical workflow. Such scheduling practices may inadvertently intensify feelings of inadequacy and reinforce concealment behaviours during the vulnerable early residency period. There are important pre-residency considerations that also warrant attention (Table 3, Column 3). Similar to existing literature, C-IMGs in our study who did an intern year abroad, or participated in Canadian electives before residency reported a smoother transition than those without such experiences (7). While they experienced many similarities in their transition, what was different was that they had a prior experience working as part of a team to participate in patient care duties instead of purely observing (15, 17). This led us to ask whether undergraduate programs should be encouraged to provide these types of pre-residency opportunities to their students seeking residency in Canada (14, 18). Once accepted to residency, resident and attending participants in our study wondered if a pre-residency transition program with graduated clinical experience (similar to programs offered for I-IMGs in some institutions) could be helpful for C-IMGs (14, 37). However, such programs must be designed carefully to ensure C-IMG recruitment equity (38) and balance “othering” of C-IMGs in early residency (7, 30), as the intent would be to diminish, not exacerbate negative feelings. Limitations This study has several noteworthy limitations. While we attempted to recruit a range of participants from various Canadian IM programs and international undergraduate schools, not all C-IMG journeys were captured in our study. Thus, transfer to other settings may require further contextualization. While our findings were focused on C-IMGs, and while hiding in plain sight is likely quite unique to them it is possible that several IMGs may share similar experiences to participants in our study; this could be explored in future research. Similarly, while we studied Canadians studying abroad and returning to Canada, other IMGs who are returning for residency to their home country warrant study as well. Participants were not purposefully sampled based on gender, race, or cultural factors. However, we are mindful that C-IMGs hold numerous personal identities at once (39, 40), and these intersecting factors may contribute to social identity and feelings of self-doubt, thus, they are important considerations for future research (32, 41). Conclusion As in Canada (7, 20), IMGs who study abroad and return to their home country for residency are an important and valued part of many countries’ physician workforce (4, 6, 20). Focused on the Canadian context, we provide novel insights into their experiences integrating into residency and practical recommendations for supporting these trainees, emphasizing the role of authentic mentorship to foster visibility of training status, validation of their challenging journey and individualized guidance. IMGs of all types face significant challenges in their journey returning to their home countries for residency, and those adversities do not stop upon acceptance to a postgraduate program (7, 15, 18). We encourage educators internationally to identify whether IMGs or similar trainees are ‘ hiding in plain sight’ in their programs, adapt these recommendations and measure impact. Further, we call for broader research on the topic of IMGs returning to their home countries for residency. Declarations Ethics approval and consent to participate: This study was approved by the Research Ethics Board at Western University, Ontario, Canada (REB #121311). Written informed consent was obtained from all participants prior to their interviews. All methods were carried out in accordance with the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans (TCPS2). Consent for publication: Not applicable Availability of Data and Materials: The datasets generated during this study are not publicly available to protect participant confidentiality. Reasonable requests for information can be directed to the corresponding author. Competing Interests: Not applicable Authors Contributions: Z.M conceived the study and developed the research question, designed the study methodology and interview guide with the input of K.A.B, J.T and M.G. Z.M and K.A.B recruited participants and Z.M conducted all interviews. Z.M led the data analysis using constructivist grounded theory methodology. K.A.B, J.T and M.G provided methodological oversight and participated in iterative data analysis and thematic development. Z.M drafted the initial manuscript. K.A.B, J.T, and M.G provided critical revisions for important intellectual content. All authors read and approved the final manuscript and agree to be accountable for all aspects of the work. Funding/Support: None Use of Artificial Intelligence: The authors used generative AI models [GPT-5, Microsoft Copilot, Claude (Anthropic)] for language editing and manuscript organization during the preparation of this work. The tools were used to refine the abstract and to improve clarity and flow for certain challenging sentences in the introduction, methods, results and discussion. No confidential or unpublished data were entered into the AI systems. All AI-generated content was thoroughly reviewed, edited and verified by the authors, who take full responsibility for the final manuscript. 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Supporting international medical graduates' transition to their host-country: realist synthesis. Med Educ. 2016;50(10):1015–32. Khan FCS, Shafiullah M, Nasiri M, Saraf A, Sehgal T, Rana A, Tadros G, Kingston P. International Medical Graduates (IMGs) in the UK—a Systematic Review of Their Acculturation and Adaptation. Int Migration Integr. 2015;16:743–59. Boulet JCR, Seeling S, Norcini J, McKinley D. U.S. Citizens Who Obtain Their Medical Degrees Abroad: An Overview, 1992–2006. Health Aff. 2009;28(1):226–33. Najeeb U, Wong B, Hollenberg E, Stroud L, Edwards S, Kuper A. Moving beyond orientations: a multiple case study of the residency experiences of Canadian-born and immigrant international medical graduates. Adv Health Sci Educ Theory Pract. 2019;24(1):103–23. Mok PS, Baerlocher MO, Abrahams C, Tan EY, Slade S, Verma S. Comparison of Canadian medical graduates and international medical graduates in Canada: 1989–2007. Acad Med. 2011;86(8):962–7. Zulla R, Baerlocher MO, Verma S. International medical graduates (IMGs) needs assessment study: comparison between current IMG trainees and program directors. BMC Med Educ. 2008;8:42. Beran TN, Violato E, Faremo S, Violato C, Watt D, Lake D. Ego identity development in physicians: a cross-cultural comparison using a mixed method approach. BMC Res Notes. 2012;5:249. Hall P, Keely E, Dojeiji S, Byszewski A, Marks M. Communication skills, cultural challenges and individual support: challenges of international medical graduates in a Canadian healthcare environment. Med Teach. 2004;26(2):120–5. Sockalingam SHR, Battran M, Abbey S, Zaretsky A. Preparing International Medical Graduates for Psychiatry Residency: A Multi-Site Needs Assessment. Acad Psychiatry. 2012;36:277–81. Legassie J, Zibrowski EM, Goldszmidt MA. Measuring resident well-being: impostorism and burnout syndrome in residency. J Gen Intern Med. 2008;23(7):1090–4. Mathews MRD, Bourgeault I. I wish I had known what I was getting into: a qualitative study exploring the experiences of Canadians who study medicine abroad. BMC Med Educ. 2023;23(376). Cavett T. The Stigmatization of Internationally Educated Family Medicine Residents at the University of Manitoba. University of Manitoba; 2015. Mannes MM, Thornley DJ, Wilkinson TJ. Cross-cultural code-switching - the impact on international medical graduates in New Zealand. BMC Med Educ. 2023;23(1):920. Sless RT, Hayward NE, Ryan PM, Kovacs-Litman A, Najeeb U. Lessons from across the pond: Student perspectives on the Internal Medicine clerkship experience at an Irish and Canadian medical school. MedEdPublish (2016). 2020;9:16. Wongprom I, Ruangsomboon O, Huang J, Ghavam-Rassoul A. International medical learners and their adjustment after returning to their countries of origin: a qualitative study. BMC Med Educ. 2024;24(1):731. Wong A, Lohfeld L. Recertifying as a doctor in Canada: international medical graduates and the journey from entry to adaptation. Med Educ. 2008;42(1):53–60. (CAPER) CPMDER. The National IMG Database Report. 2023 [Available from: https://caper.ca/postgraduate-medical-education/census-data-tables Charmaz K. Constructing Grounded Theory. 2nd ed. Los Angeles: Sage; 2014. Panju M, Whitehead L, Martin L. The Core Internal Medicine Training: Evolving beyond the Clinical Teaching Unit. Can J Gen Intern Med. 2020;15(1):e8–11. Ramani SMK. Introducing medical educators to qualitative study design: Twelve tips from inception to completion. Med Teach. 2016;38(5):456–63. LaDonna KAA, Balmer D. Beyond the Guise of Saturation: Rigor and Qualitative Interview Data. J Graduate Med Educ. 2013:607–11. Olmos-Vega FSR, Varpio L, Kahlke R. A practical guide to reflexivity in qualitative research: AMEE Guide 149. Med Teach. 2023;45(3):241–51. Gupta S, Detsky A. Prioritizing Continuity in Canadian Clinical Teaching Units. CMAJ. 2014;186(10):800. Angus S, Vu TR, Halvorsen AJ, Aiyer M, McKown K, Chmielewski AF, et al. What skills should new internal medicine interns have in july? A national survey of internal medicine residency program directors. Acad Med. 2014;89(3):432–5. Chodoff A, Conyers L, Wright S, Levine R. I never should have been a doctor: a qualitative study of imposter phenomenon among internal medicine residents. BMC Med Educ. 2023;23(1):57. Sandon JE. Passing in American Culture. English. 2013;1. Morrison N, Machado M, Blackburn C. Student perspectives on barriers to performance for black and minority ethnic graduate-entry medical students: a qualitative study in a West Midlands medical school. BMJ Open. 2019;9(11):e032493. Kerins J, Smith SE, Tallentire VR. Us versus them': A social identity perspective of internal medicine trainees. Perspect Med Educ. 2022;11(6):341–9. Burford B. Group processes in medical education: learning from social identity theory. Med Educ. 2012;46(2):143–52. Bandyopadhyay S, Boylan CT, Baho YG, Casey A, Asif A, Khalil H, et al. Ethnicity-related stereotypes and their impacts on medical students: A critical narrative review of health professions education literature. Med Teach. 2022;44(9):986–96. Sawatsky AP, Matchett CL, Hafferty FW, Cristancho S, Ilgen JS, Bynum WE, et al. Professional identity struggle and ideology: A qualitative study of residents' experiences. Med Educ. 2023;57(11):1092–101. PR Clance SI. The imposter phenomenon in high achieving women: Dynamics and therapeutic intervention. Psychotherapy: Theory, research & practice. 1978;15(3):241-7. Baker J. Feedback for Clinical Skills in Medical Education. How to Provide Authentic Feedback in Medical Education. Cham: Springer Nature Switzerland; 2024. pp. 43–8. Pre-Entry Assessment Program (PEAP) Policy: Ontario Faculties of Medicine. 2014 [cited 2024 June 11]. Available from: https://cou.ca/wp-content/uploads/2014/05/COU-Pre-entry-Assessment-Program-Policy.pdf Inge Schabort PW, Van Gerven. Selection of international medical graduates into postgraduate training positions in Canada. Who applies? Who is selected? Canadian Medical Education Journal; 2024. Monrouxe LV. When I say… intersectionality in medical education research. Med Educ.2015;49(1):21 – 2. Crenshaw K. Demarginalizing the Intersection of Race and Sex: A Black Feminist Critique of Antidiscrimination Doctrine, Feminist Theory and Antiracist Politics. Univ Columbia. 1989;139. LaDonna KA, Ginsburg S, Watling C. Rising to the Level of Your Incompetence: What Physicians' Self-Assessment of Their Performance Reveals About the Imposter Syndrome in Medicine. Acad Med. 2018;93(5):763–8. Tables Table 2. Representative Quotes from Participants Representative Quotes Related to Critical Period of Growth and Catching Up Differences in Undergraduate Training “... more of an observership. You're not really putting in orders. You're not really contributing very much to patient management. Your goal is to be present. Observe, learn by osmosis, and then carry out physical examinations and histories and present them, but not really to take responsibility for patients to the same extent that our medical students would be doing here.” (Pr12). Catch Up Period “As I went through more CTU rotations, I very much learned by…modeling. So, it was seeing more senior residents and how they do things, seeing more of how the other co-residents do things and just picking up on those things and adding those to my day to day and that made me feel more comfortable... by the time I got to my second set of [CTU] rotations, which is…midway through the year, I felt more comfortable, which is what people usually say happens. And then it was the positive feedback along the way from staff supervisors. And that really helped me feel a little bit more comfortable and realize that I deserve to be there…You know, I was doing an okay job.” (Pr8). Phase of Disorientation “ I had no prior exposure to the [CTU] here prior to starting…and we had received training online for how to use the [electronic medical record] on how to write a [consult] note... but I had never received hands on training… so I remember my first night shift…I did not know how to do anything. I had to rely on the [final year] medical student to help me figure out where to find stuff on [the computer], how to order stuff, how to get around even and what my job is really like…what my responsibilities are.” (Pr3). Making Clinical Decisions “I found that a lot of the other residents were like, okay, [I think this patient has pneumonia] - maybe [let’s start] Ceftriaxone, Azithromycin, [a litre] of [normal saline], you know, it was kind of like they knew the [exact] steps where my knowledge base was mainly… [let’s start] some form of antibiotics and fluids and basic blood work at some time intervals. But I feel like they had a lot of those detailed steps down like way earlier than I did.” (Pr7). Prematurely Asking for Help “I think on one of my first few days, my patient [had] tachycardia…I escalated it to my [senior medical resident] …right away before…[I] had literally done anything. And I think…they said that, you know, that’s great…maybe …do these simple tests [first]. And I [realized], [I]…had known, I knew how to do that. But I was so nervous... Just seeing whatever that clinical presentation was [for the first time].” (Pr2). Delayed Seeking Help “At the start…it gave me a bit of paralysis…I think it did get in the way…I would think all my [Canadian graduate peers] already know this, so I should be expected to know…this is just something that I’ll take on myself and figure it out on my own because it would be telling if I revealed that I didn’t know this. So, there was some anxiety around that.” (Pr8). Intern Year Prior to IM Residency “You’re observing a lot, and you would see how care plans are being advanced, and you would write the discharge summaries…so you participate actively in [patient] care, but you're never making a decision by yourself and you're never going and assessing a patient really by yourself during the day…” (Pr10). Representative Quotes Relating to Emotional Toll and its Lingering Effect Emotional Toll “ I had a call shift, the second day of my training, and I was carrying three pagers for three different teams. And I just felt completely overwhelmed. The pager went off for me to see a patient…and so I left the…call room and I was walking towards…trying to find this room and ended up getting lost in the basement of the hospital. And I… just burst into tears… I found a bathroom and just basically cried because I was like, so flustered and I felt so like useless. Like, I didn't even know where to go. And I just felt completely overwhelmed.” (Pr5). Lingering Effect “Now I feel on par…But it's taken years to get here. I never felt on par in residency [when I was a C-IMG]. I remember getting feedback once from [a] really an excellent IM attending…he pulled me aside in my PGY3 year and he said… you probably get this all the time, but you're the strongest resident I've ever worked with. And I remember going, I don't know what you're talking about. I feel like I'm so weak.” (Pa17). Skewed Frame of Reference “…It was one of my first shifts and I got…I think 28 consults that came in …and I had to stop it at consult number 16 by 5 a.m.…I took that on as like I had failed ...It was my own personal flaw …it wasn't until a while later of going through night float and figuring out how things go and what is reasonable for my level and talking to other people that I was able to…get over that.” (Pr8). Abbreviations: PGY3= post-graduate year 3 CTU= Clinical Teaching Unit Table 3. Participant and Research Team Suggestions with Representative Quotes around Creating an Environment to Support IMGs, Including C-IMGs Suggestions by Participants Representative Quotes Research Team Suggestions Pre-Residency Canadian electives during undergraduate years Shadowing experience Graduated patient care responsibilities “I got to see…what the Canadian medical students were doing and the residents and see what the expectations were. So, by the time I came in on July [1st], even though maybe I hadn't had as much experience, I knew [what] was going to be a deficit.” (Pr2). “If you could…shadow or something more practical…follow around one of the junior residents…for a couple of days…see what the patient load is…I would have loved to do that.” (Pr4). Prior to residency, consider opportunities such as Intern year or Canadian electives. Provide opportunities for IMGs to actively participate in low-stakes clinical activities before or at the beginning of residency to learn the expectations as first-year residents, such as their role and clinical responsibilities. During Residency à Mitigating Disorientation Thoughtful scheduling of IMG residents Bootcamp at the start of residency PGY1 handbook Iterative feedback from residents IMG workshop “Not being put on call July 1st would have been so huge for me…and even graduated call or call the second week so that you at least have a sense of how things work… it just adds to the feeling of being super overwhelmed if you're just thrown into a 26-hour shift and you have no idea what's going on…I don't know if it would be helpful or not helpful to be starting [residency] on CTU and to this day I still don't know.” (Pr4). “… we had a focus group with all our C-IMGs and I-IMGs, this is where our bootcamp was born out of…. the residents are saying hey this is an issue this is relevant to us…And that's the way we…developed a lot of this in the last 2 years….and we also see that through our quality improvement process…” (Pa18). “You can have a -very non-judgemental- workshop, create a [safe environment], to get to know [C-IMGs] better, see if they think…hey, I would like to develop more in this area…bring cases…share tips.” (Pa14). Programs should engage in intentional and mindful scheduling of IMGs, especially when considering overnight call duties, first rotations and burnout. A residency orientation handbook and “bootcamp orientation” should be provided to all residents, including IMGs. Other interventions such as an IMG or specific I-IMG and C-IMG workshop(s) can be considered. All program interventions should undergo iterative feedback by IMGs and other stakeholders. During Residency à Authentic Mentorship Making sure rotation leaders and attendings are aware of IMG learning needs Authentic mentorship Frequent Check-ins Peer mentorship with other C-IMGs “Correct placement and orientation of the people who are in power positions and their supervisors.” (Pa17). “Making sure each attending is fully aware of what their [C-IMG resident] is coming with and what they need.” (Pa16). “ I…started to realize that my feelings and just [the] huge learning curve and adjustment was not just specific to me and that other people experienced it…[my attending] really validated my feelings and she herself was not an IMG but she said a lot of her colleagues were, and that they were excellent physicians and she knew for a fact that they also cried their first summer ….I feel like it was like it was almost more her than me, to be honest in terms of initiating that conversation.” (Pr4). “I sit down with [C-IMGs] and say, look, you probably have great clinical skills. I know you’re smart and that you’ve studied for the Canadian exams …but your patient management skills are going to be lagging because you just haven’t done that before...and that’s okay, it’s not okay to stay where you are. I’m going to push you in a graduated fashion. And I’m going to suggest resources for you. And the goal is by six months you are in step with your average Canadian graduate when it comes to patient management skills. That includes things like requestions and paperwork, facilitating family meetings, discharge summaries, writing a prescription. And importantly…making decisions with a healthy degree of initiative and testimony.” (Pa17). “Regular check ins about how we're doing…having set objectives to work on efficiency.” (Pr8). “…to have somebody a year ahead of you who is a C-IMG, [who you can] discuss [with] and get help from, on a day-to-day basis…even having a road map of what the new year of residency will hold for you.” (Pr5). All attendings that have the potential to supervise an IMG should be primed about a typical I-IMG and C-IMG’s educational journey prior to residency, the challenges they experience and their unique learning needs. Consider pairing an IMG with an experienced and motivated mentor who is separate from their supervisor, to have frequent check-ins about the IMG experience navigating residency. Programs should be mindful that attendings who are supervising IMGs at the start of residency are experienced in working with struggling learners. These attendings should be encouraged to have frequent feedback sessions with the IMG, ensuring to reconcile their feedback with the IMG’s self-assessment and to openly discuss challenges and next steps. Facilitate a network of vertical near-peer mentors (such as senior residents from the same program) who can be vulnerable and transparent about initial challenges and provide support to C-IMGs. This mentorship should start before residency and persist past post-graduate year 1. Abbreviations: C-IMGs= Canadian-International Medical Graduates; CTU= Clinical Teaching Unit, I-IMGs= Immigrant-International Medical Graduates; IMG= International Medical Graduate Additional Declarations No competing interests reported. Supplementary Files Appendix.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 26 Feb, 2026 Reviews received at journal 16 Feb, 2026 Reviewers agreed at journal 13 Feb, 2026 Reviewers agreed at journal 12 Feb, 2026 Reviewers agreed at journal 08 Feb, 2026 Reviewers invited by journal 06 Feb, 2026 Editor invited by journal 19 Jan, 2026 Editor assigned by journal 17 Jan, 2026 Submission checks completed at journal 17 Jan, 2026 First submitted to journal 12 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8585367","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":588342834,"identity":"344a7181-30e8-439e-855f-650fc7ea1572","order_by":0,"name":"Zahra Merali","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6UlEQVRIie3PMYvCMBTA8RcKd0ug6xtK+xVSMoiD+lUuZO05ipsRoS4V1/hFnFsKd4vnF8hy7h0yOjgYKIJLoG4O+U+PwI/3AhAKvWX0MUSqti8SohoNrJ8Gk4gOIdn278de4ZiOts26nZQ3N+x+/y1MMx8h1VweKjA8OQnVfpfMDWex1iBz36oICu5uM0JDT4TGIt9QqL3XfcQdJzcwKx1fVDt+IjMfoVhw92vzhei2kCcifASx41HCTK7xoprqzDnSU37QTEofyfYFJ93SZBjL1l4XaYqfFbN2OZ34SB8b8BIKhUKhF7oDm7ZTEip+eD0AAAAASUVORK5CYII=","orcid":"","institution":"University of Toronto","correspondingAuthor":true,"prefix":"","firstName":"Zahra","middleName":"","lastName":"Merali","suffix":""},{"id":588342841,"identity":"44c68a7c-b619-48fe-af02-78a6f0ffb567","order_by":1,"name":"Kristen A Bishop","email":"","orcid":"","institution":"Western University","correspondingAuthor":false,"prefix":"","firstName":"Kristen","middleName":"A","lastName":"Bishop","suffix":""},{"id":588342848,"identity":"c0d4014b-593b-449f-865a-56b5e8c7ccb0","order_by":2,"name":"Jacqueline Torti","email":"","orcid":"","institution":"Western University","correspondingAuthor":false,"prefix":"","firstName":"Jacqueline","middleName":"","lastName":"Torti","suffix":""},{"id":588342854,"identity":"3e683111-b055-4623-9200-7fdf83389c07","order_by":3,"name":"Mark Goldszmidt","email":"","orcid":"","institution":"Western University","correspondingAuthor":false,"prefix":"","firstName":"Mark","middleName":"","lastName":"Goldszmidt","suffix":""}],"badges":[],"createdAt":"2026-01-12 21:23:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8585367/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8585367/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102439461,"identity":"6fb15e6c-3085-4826-a914-687f7f70deb5","added_by":"auto","created_at":"2026-02-11 16:40:28","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":193554,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eHiding in Plain Sight\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8585367/v1/d9494d8f321c22c3412179fd.png"},{"id":102439510,"identity":"b1a4956b-6bb3-40cc-bcc2-f807b371ccf0","added_by":"auto","created_at":"2026-02-11 16:40:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1224279,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8585367/v1/6265919f-bc77-4492-8eff-587cf3e53363.pdf"},{"id":102439495,"identity":"c319e675-eaba-43ca-957b-6b0aefb2dc77","added_by":"auto","created_at":"2026-02-11 16:40:36","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":20730,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix.docx","url":"https://assets-eu.researchsquare.com/files/rs-8585367/v1/2c535c73115bac754f9a9dbc.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Title: ‘Hiding in Plain Sight’: A Qualitative Study of International Medical Graduates Returning to Their Home Country for Internal Medicine Residency","fulltext":[{"header":"Background","content":"\u003cp\u003eThe transition into residency in one\u0026rsquo;s home country after attending medical training abroad is challenging for medical trainees internationally (\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). International medical graduates (IMGs)- physicians who practice medicine in a country different from where they were trained- comprise a substantial proportion of the medical workforce globally, including over 40% in Australia, Ireland, Israel, New Zealand and Norway, 40% in the United Kingdom and 25% of practicing doctors in North America (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). IMGs struggle with integration into their postgraduate training programs, even those who are citizens in their home country (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Challenges include perceived discrimination (\u003cspan additionalcitationids=\"CR8 CR9 CR10 CR11\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), self-doubt (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) and difficulties with orienting and transitioning to residency (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWithin the IMG population, important distinctions exist between immigrants with a medical degree from another country (I-IMGs) and citizens who studied abroad and return home for postgraduate training (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Despite the growing prevalence of citizens pursuing medical education abroad internationally (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e), most studies on IMG integration in residency do not differentiate between these subgroups (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), leaving the experiences of returning citizens poorly understood. The few studies that do differentiate between IMG types are based in Canada and separate IMGs into I-IMGs and Canadian citizens who have studied abroad (C-IMGs) (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). These studies reveal important differences: while I-IMGs- some of whom have practiced medicine prior to immigrating (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)- highlight cultural transition and communication barriers as specific challenges, C-IMGs report different struggles, including adapting to clinical responsibilities, overnight call expectations and other nuances of the healthcare system navigation (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Further distinguishing C-IMGs are their ability to \u0026ldquo;blend in\u0026rdquo; with their Canadian graduate peers (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The fact that they are IMGs can, at times, be unknown to their supervisors, leaving them to struggle with critical competencies without necessary supports (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMost program supports for IMGs focus on the cultural transition to residency (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), which C-IMGs perceive as largely irrelevant to their needs (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Few studies have attempted to understand the unique challenges that C-IMGs face (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e), and even fewer are focused on specialities such as Internal Medicine (IM) (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), where C-IMGs represent approximately 11% of residents (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Understanding these experiences is essential for developing adequate interventions and program supports that are tailored to meet their unique needs.\u003c/p\u003e \u003cp\u003eThe purpose of this study was to explore the integration experiences of IM C-IMGs, as perceived by themselves and those around them. In doing so, we hoped to gain novel insights into how best to support IM C-IMGs as they transition into and through their residency programs. While this study focuses on the Canadian context, our findings may inform programs in other countries facing similar workforce dynamics (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eA constructivist grounded theory approach was chosen because it is ideal for studying complex social phenomena where theory development could help provide novel insights\u0026ndash; in this case, novel insights into the experiences of C-IMGs in IM residency (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). We interviewed IM C-IMG residents with shared yet distinct experiences in Canadian residency programs and program directors or designated faculty (defined as attendings who have a leadership role in training C-IMGs, as identified by the program director). We selected C-IMG residents who had completed at least one year of post-graduate training, given that their first-hand experience and opportunity to reflect positioned them as an ideal group to offer insights into personal education and program needs. Program directors (or designated faculty) often oversee the experience of C-IMGs and are responsible for program development and refinement, making their perspectives also important. IM was chosen as the specialty program of interest given the high clinical responsibility, the residency demands and the paucity of literature in this area (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Recruitment was completed through email via program administrators from the 14 IM programs in Canada that accepted C-IMGs at the time of study (University of Ottawa, Queen\u0026rsquo;s University, University of Toronto, McMaster University, Western University, University of Manitoba, University of Saskatchewan, University of Alberta, University of Calgary, University of British Columbia, Universit\u0026eacute; Laval, Universit\u0026eacute; de Sherbrooke, Universit\u0026eacute; Montreal, McGill University), social media, and snowball sampling (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) after the initial interviews. Virtual semi-structured individual interviews and focus groups (to accommodate participants located across Canada) were conducted with post-graduate year (PGY)-2 to PGY-6 IM residents and program directors (or designated faculty) across Canada. This study was approved by the Western University Research Ethics Board.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData Collection and Analysis\u003c/h3\u003e\n\u003cp\u003e Prior to each interview, informed consent was obtained. A total of 17 individual interviews and two focus groups (including three to four participants each) were conducted by Z.M. The interviews ranged from 40\u0026ndash;72 minutes (average 56 minutes). Our interview guide was revised iteratively as we gained new insights through each interview [Appendix A, Appendix B].\u003c/p\u003e \u003cp\u003eConsistent with constructivist grounded theory, data collection and analysis took place iteratively (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). The first five transcripts were selected for open coding. Coding was supported by NVivo software, version 12 (QSR International). Transcripts were de-identified by Z.M. and read recursively by Z.M., M.G., and K.A.B. and then reviewed across a series of meetings, leading to the creation of a set of focused codes. Challenges or uncertainties encountered during coding were resolved through discussions at regular research team meetings.\u003c/p\u003e \u003cp\u003eTo support rigour, constant comparison was also used; as new insights emerged, new codes were added and definitions for focused codes were updated. All previously coded transcripts were then re-read and re-coded. Constant comparison was also used as we identified thematic categories across our codes and tried to understand their relationship to each other, which helped us develop our theory (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). For the purpose of clarification and refinement of key concepts, the developed theory was then presented during further focus groups or individual semi-structured interviews with a subgroup of existing and new participants as a form of member checking. Data collection and analysis ceased when members of the research team felt that further sampling would provide no greater insight into the theoretical model, also known as theoretical sufficiency (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Rigour was further supported through reflexive memo-ing [Appendix C] and investigator triangulation (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eReflexivity\u003c/h3\u003e\n\u003cp\u003eZ.M. is an early-career IM physician who is a C-IMG herself. This was a very personal study, and being an insider was helpful during the interviews as it allowed Z.M. to engage meaningfully in what were often shared experiences with resident participants. The research team also consisted of M.G. (PhD education researcher and an experienced IM attending physician who supervises C-IMGs) and two non-clinician PhD medical education researchers (K.A.B. and J.T.) who helped to challenge the primary author\u0026rsquo;s assumptions and experiences through frequent meetings. As part of regular reflexive dialogue, Z.M. was asked questions such as \u0026ldquo;Was this true to you or true to the data?\u0026rdquo; These conversations helped to enhance the richness of our analysis (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Since the data collection, Z.M has had the opportunity to augment her own experience as a C-IMG and the experiences from those she interviewed, which has helped her provide meaningful mentorship to C-IMGs she supervises in her practice.\u003c/p\u003e\n\u003ch3\u003eStudy Context\u003c/h3\u003e\n\u003cp\u003eIn Canada, IM residency is four years with the option to subspecialize in postgraduate years four and five. During training, residents rotate between the IM inpatient teaching service, frequently called the clinical teaching unit (CTU), and other subspeciality services such as Cardiology, Gastroenterology and Critical Care (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Canadian medical students in their core rotations (six to eight weeks) are expected to take responsibility for patient care on the CTU with graduated supervision by senior team members (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Likewise, in the United States, many undergraduate programs offer an IM \u0026ldquo;sub-internship,\u0026rdquo; for students to serve as acting interns with similar expectations for a four-week rotation (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). In contrast, in several European countries, such as Ireland, medical students see several different patients and are expected to present structured histories and examination findings for practice, followed by questions from their attendings about the pathophysiology and management of relevant conditions, but their presentations rarely inform decisions around patient care. Patient care responsibilities are delayed until intern year (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eIn total, 19 participants from IM programs across Canada were interviewed between January 2023 and April 2024 [Table 1]. \u0026nbsp;As depicted in Figure 1, our main study finding relates to the experience of both wanting and being able to \u003cem\u003ehide in plain sight\u003c/em\u003e which, at times, was to their own detriment. For some, it started pre-residency when hearing about other C-IMGs and the stigma they experienced during their transitions to residency. It could also be developed and reinforced early on during their own transitions. Although participants felt they had strong theoretical knowledge, their patient care experiences from undergraduate training were mostly observational leading to a \u003cem\u003ecritical period of growth\u003c/em\u003e during which they had to \u003cem\u003ecatch up\u003c/em\u003e to their Canadian graduate peers. Moreover, over time, even with objective evidence that they had caught up, many described a \u003cem\u003elingering effect\u003c/em\u003e of self-doubt and inadequacy. In the following sections, we will describe each of these aspects in more detail and share participant perspectives on ways to improve the C-IMG early residency experience to diminish the feeling of needing to hide. Quotations from residents are represented by \u0026ldquo;Pr\u0026rdquo; (Pr1-12) and program directors or designated faculty (hereafter referred to as attendings) are represented by \u0026ldquo;Pa\u0026rdquo; (Pa13-19).\u0026rdquo;\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"680\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1. Demographic Details\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eC-IMG Participants\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal 12\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eProgram Directors or Designated Faculty\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal 7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost-graduate Year (PGY)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePGY2-3s\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePGY4-6s\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eUndergraduate Country\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost-graduate Program University*\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost-graduate Program Region*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIreland\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMcMaster University\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOntario\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAustralia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUniversity of Manitoba\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eWestern Canada\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePoland\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUniversity of Ottawa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUnited Kingdom\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWestern University\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNew Zealand\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003eAbbreviations: C-IMG= Canadian-International Medical Graduates\u003c/p\u003e\n \u003col\u003e\n \u003cli\u003eNote: Further demographic details for all participants are withheld to protect anonymity.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e*Only post-graduate programs that accept IMGs were included in recruitment: University of Ottawa, Queen\u0026rsquo;s University, University of Toronto, McMaster University, University of Manitoba, University of Saskatchewan, University of Alberta, Western University, University of Calgary, University of British Columbia, Universit\u0026eacute; Laval, Universit\u0026eacute;\u0026nbsp;de Sherbrooke, Universit\u0026eacute;\u0026nbsp;Montreal, McGill University\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 1. Hiding in Plain Sight\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAbbreviations: C-IMG= Canadian-International Medical Graduate\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eImage created on: Canva.com\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eAlt Text:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFigure showing the \u0026ldquo;Hiding in Plain Sight\u0026rdquo; concept: an iceberg diagram illustrating visible and hidden aspects of Canadian-International Medical Graduate experiences during the transition to residency\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eHiding in Plain Sight\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;As a new resident, I don\u0026apos;t want a big halo on my head like a character in a video game that says, I\u0026apos;m an IMG\u0026hellip;I want to blend in and\u0026hellip;be one of the of \u0026lsquo;the boys\u0026rsquo;\u0026hellip;without being different\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Pr1).\u003c/p\u003e\n\u003cp\u003eAs described by C-IMG Participant 1 in [Table 2], many C-IMG participants expressed a desire to hide their training status in early residency because of the perceived stigma of being a C-IMG. They were often successful in doing so because growing up in Canada, they \u0026lsquo;fit in\u0026rsquo; culturally.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e[Table 2 here]\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eC-IMG and attending participants expressed how \u003cem\u003e\u0026ldquo;C-IMGs\u0026hellip;may be [perceived as] less clinically strong than [Canadian graduates]\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Pr2). A few C-IMG participants highlighted that they were aware of this perception of a \u003cem\u003e\u0026ldquo;negative tone around C-IMGs\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Pr5) while still in medical school through colleagues who had already returned to the Canadian system as C-IMGs. Several C-IMGs also indicated that this perception was reinforced during residency, leading many C-IMG participants to \u0026ldquo;\u003cem\u003ewant to blend in\u003c/em\u003e\u0026rdquo; (Pr1) and hide their status of being other. This, in some cases \u0026ndash; as further elaborated in the sections below \u0026ndash; permeated their actions during their \u003cem\u003ecritical period of growth\u003c/em\u003e by changing the way they sought help from others (if at all) and impacted their relationships with their peers. This perceived need to hide also compounded the emotional toll of early residency, and the ability or willingness to disclose their struggles to potential sources of support. Some C-IMG participants, such as Participant 4 in [Table 3], described that during this challenging timeframe they experienced relief at a moment of unmasking, or open, authentic acknowledgement of their C-IMG status. In this case, it was a conversation initiated by their attending where they \u0026ldquo;\u003cem\u003evalidated my feelings\u003c/em\u003e\u0026rdquo; by describing they knew other IMGs who \u0026ldquo;\u003cem\u003ealso cried during their first summer\u003c/em\u003e\u0026rdquo; and were now \u0026ldquo;\u003cem\u003eexcellent physicians\u003c/em\u003e\u0026rdquo; (Table 3, Row 2, Column 3, Pr4).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e[Table 3 here]\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCritical Period of Growth and Catching Up\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs shown in Table 2, due to \u003cstrong\u003edifferences in their undergraduate training\u003c/strong\u003e, the first year of residency was a \u003cem\u003ecritical period of growth\u003c/em\u003e where participants felt they needed to \u003cem\u003ecatch up\u003c/em\u003e to their Canadian graduate peers. While the \u003cstrong\u003e\u003cem\u003ecatch up\u003c/em\u003e period\u003c/strong\u003e was concentrated in the first two months of residency,\u0026nbsp;participants varied in their descriptions of it lasting between \u003cem\u003e\u0026ldquo;a few months\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Pr2, Pa13, Pa14, Pa15), \u003cem\u003e\u0026ldquo;by month 3-4\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Pr4, Pr5, Pr7, Pa18) and \u003cem\u003e\u0026ldquo;the first 6-12 months\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Pr1, Pr3, Pr6, Pr8-12, Pa16, Pa17, Pa19), during which they gained knowledge about institution specific processes, clinical knowledge, abstract reasoning skills and subsequently, comfort and confidence.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants could not identify specific resources that helped them \u003cem\u003ecatch up\u003c/em\u003e, but rather described the importance of experiential learning: \u003cem\u003e\u0026ldquo;\u0026hellip;it\u0026rsquo;s just a matter of time and experience\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Pr1); another described: \u003cem\u003e\u0026ldquo;getting a lot of clinical experience really quickly upfront\u0026hellip;I guess you kind of sink or swim, right, and you just get that experience and you move forward\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Pr2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn terms of explaining why this happened,\u0026nbsp;when discussing the difference between the C-IMG undergraduate experience compared to that of Canadian graduates, many C-IMG participants described their prior training as:\u0026nbsp;\u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003cem\u003emore of an observership\u003c/em\u003e\u0026hellip;\u0026rdquo; (Table 2, Pr12)\u003cem\u003e,\u0026nbsp;\u003c/em\u003eor,\u0026nbsp;theoretical \u0026ndash; focused on book knowledge, clinical skills and physical exams without the chance to apply theoretical knowledge in practice.\u0026nbsp;In contrast, participants flagged how Canadian medical students act in a clerkship or intern role, where, in a graduated fashion, they are responsible for the direct care of a select number of patients on their team.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDue to this difference in training, unlike C-IMGs, Canadian medical students had the chance to become familiar with how to function effectively on their IM rotation. Participant C-IMGs described being in a \u003cstrong\u003ephase of disorientation\u003c/strong\u003e, where they were burdened with \u003cem\u003e\u0026ldquo;the stress of the unknown\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Pr4), whichcreated a sense of feeling \u003cem\u003e\u0026ldquo;lost\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Pr5, Pr6) and not knowing \u0026ldquo;\u003cem\u003ehow to do anything\u003c/em\u003e\u0026hellip;\u0026rdquo; (Table 2, Pr3). Other C-IMG participants highlighted that there was a lack of awareness of their expectations as a first-year resident. For example, one resident participant described the experience on their first day, splitting the list in the morning, going off to see their own patients, and feeling \u0026ldquo;\u003cem\u003e[shocked and intimidated] that I was rounding on all my patients [alone]\u0026rdquo;\u0026nbsp;\u003c/em\u003enot realizing that the senior resident and attending would also be seeing the patient \u0026ldquo;\u003cem\u003ein the background\u0026rdquo;\u003c/em\u003e (Pr2). Further, C-IMGs felt that when it came to \u003cstrong\u003emaking clinical decisions\u003c/strong\u003e, they theoretically knew how to treat different disease patterns, but unlike their Canadian graduate peers, they couldn\u0026rsquo;t articulate \u003cem\u003e\u0026ldquo;the exact steps\u0026rdquo;\u003c/em\u003e (Table 2, Pr7) to treat their patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBoth C-IMG and attending participants noted their experiences and performance gaps were separate from I-IMGs. One participant, when comparing themselves to I-IMGs, described that I-IMGs had significant experience \u003cem\u003e\u0026ldquo;under their belt in terms of practice and knowledge,\u0026rdquo;\u0026nbsp;\u003c/em\u003eand they themselves \u003cem\u003e\u0026ldquo;wished I had that experience going into residency,\u0026rdquo;\u0026nbsp;\u003c/em\u003einstead feeling like \u003cem\u003e\u0026ldquo;the least experienced person on the team despite being born in Canada\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Pr4).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThroughout this initial period, the C-IMGs perceived need to hide impacted relationships with their peers, their educational opportunities in early residency and their experiences receiving feedback from attendings.\u0026nbsp;When questions arose on the wards, some C-IMG participants felt \u0026ldquo;\u003cem\u003eall my [Canadian graduate peers] already know this\u0026hellip;\u003c/em\u003e\u0026rdquo; (Table 2, Pr8) and therefore would ask C-IMG peers for help and form friendships with C-IMGs more easily than Canadian graduates. They also struggled to balance their need to keep their status hidden while also engaging in support and learning opportunities. In some cases, when faced with an acute case, they \u003cstrong\u003easked for help prematurely\u003c/strong\u003e, \u0026ldquo;\u003cem\u003eescalated it\u0026hellip;right away\u0026hellip;\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Table 2, Pr2) before starting any initial management. In others, they \u003cstrong\u003edelayed seeking help\u003c/strong\u003e, as they felt they should \u0026ldquo;\u003cem\u003efigure it out on my own\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Table 2, Pr8).\u003c/p\u003e\n\u003cp\u003eA few C-IMG participants had completed an \u003cstrong\u003eintern year\u003c/strong\u003e at their international undergraduate country \u003cstrong\u003eprior to IM residency\u003c/strong\u003e in Canada. These participants, unlike the other C-IMGs interviewed, felt comfortable with night-time duties, like holding a pager or taking care of acutely unwell patients with limited support. However, even for them, team rounding, and hierarchical patient care decisions were more common in their international hospitals. Thus, daytime expectations, such as independently forming management plans, were a challenge for these residents because prior to their Canadian residency, they had \u0026ldquo;\u003cem\u003enever [been] making a decision by [themselves] and [were] never going and assessing a patient really by [themselves] during the day\u0026hellip;\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Table 2, Pr10)\u003cem\u003e.\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEmotional Toll \u0026amp; Its Lingering Effect\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I just burst into tears\u0026hellip;\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Table 2, Pr5), is one example of many vivid descriptions of the \u003cstrong\u003e\u003cem\u003eemotional toll\u003c/em\u003e\u003c/strong\u003e C-IMGs had in their transition through residency.\u0026nbsp;When discussing their initial experiences in residency all C-IMG participants revealed several negative emotions such as feeling \u0026ldquo;\u003cem\u003es\u003c/em\u003e\u003cem\u003etressed\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Pr1, Pr3, Pr4, Pr5, Pr7, Pr12), \u0026ldquo;\u003cem\u003eoverwhelmed\u0026rdquo;\u003c/em\u003e (Pr2, Pr3, Pr4, Pr7, Pr8, Pr9, Pr11, Pr12), \u0026ldquo;\u003cem\u003eanxious\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Pr4, Pr8), \u0026ldquo;\u003cem\u003escared\u0026rdquo;\u003c/em\u003e (Pr6, Pr10) and \u003cem\u003e\u0026ldquo;stupid and behind\u0026rdquo;\u003c/em\u003e (Pr12).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSome C-IMG participants felt their perceived need to hide prevented them from openly speaking of their emotions, even with their mentors: \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We did have an academic advisor\u0026hellip;they follow us for our [interim assessments], and we can talk to them about anything we need to\u0026hellip;but I didn\u0026rsquo;t feel like I could really [talk to them]. And my formal feedback was that things were going fine\u0026hellip;\u0026rdquo;\u0026nbsp;\u003c/em\u003eThe C-IMG participant expressed that they didn\u0026rsquo;t want to bring up their C-IMG challenges to avoid \u003cem\u003e\u0026ldquo;further revealing to them that I was different\u0026rdquo;\u003c/em\u003e (Pr8).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis attending encounter is discrepant from the aforementioned quote from Participant 4, who described a moment of relief when an attending initiated a conversation about their C-IMG status and \u0026ldquo;\u003cem\u003evalidated\u003c/em\u003e\u0026rdquo; their \u0026ldquo;\u003cem\u003efeelings,\u003c/em\u003e\u0026rdquo; thus, unmasking their perceived hidden status (Table 3, Row 2, Column 3, Pr4).\u003c/p\u003e\n\u003cp\u003eWhile all C-IMG participants agreed there was a \u003cem\u003ecatch up\u003c/em\u003e period, many endorsed that their individual experiences navigating the \u003cem\u003ecritical period of growth,\u0026nbsp;\u003c/em\u003eand its \u003cem\u003eemotional toll\u0026nbsp;\u003c/em\u003ehad a \u003cstrong\u003e\u003cem\u003elingering effect\u003c/em\u003e\u003c/strong\u003e: \u0026ldquo;\u003cem\u003eNow I feel on par\u0026hellip;But it\u0026apos;s taken years to get here. I never felt on par in residency\u0026hellip;\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Table 2, Pa17)\u003cem\u003e.\u0026nbsp;\u003c/em\u003eThis \u003cem\u003elingering effect\u003c/em\u003e of self-doubt, inadequacy, and a need to prove themselves lasted beyond this period and coloured the rest of their training journey. In some cases, this manifested as a \u003cstrong\u003eskewed frame of reference\u003c/strong\u003e, especially when facing challenging situations, where participants took on failures as their own \u003cem\u003e\u0026ldquo;personal flaw\u0026hellip;\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Table 2, Pr8) linked to their identity as a C-IMG, even for situations where any trainee \u0026ndash;including Canadian graduates \u0026ndash; would find challenging.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eHow to Support C-IMGs in IM Residency\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBoth attendings and C-IMGs spoke to the strengths that C-IMGs bring to Canadian postgraduate programs. In particular, their challenging journeys to and through medical school, including their experiences trying to obtain a highly sought-after residency position in Canada, led them to feel privileged and motivated to have a strong work ethic and to \u003cem\u003e\u0026ldquo;give back\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Pa19) to their programs. Attendings also placed \u003cem\u003e\u0026ldquo;tremendous value\u0026rdquo;\u003c/em\u003e on the \u003cem\u003e\u0026ldquo;diverse perspectives\u0026rdquo;\u003c/em\u003e (Pa16) that C-IMGs can contribute.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhile acknowledging the value that C-IMGs bring to Canadian programs, all participants also felt that more could be done to support them and prevent the perceived need to hide. \u0026nbsp;While unmasking is not without risk, it was felt to be important. \u0026nbsp;Several C-IMGs explicitly described relief when their training status was unmasked or openly acknowledged. \u0026nbsp;However, all felt that it needed to be done in a purposeful way. \u0026nbsp;Attending Participant 17 outlined their strategy with C-IMGs- sitting them down and acknowledging their journey \u0026ldquo;\u003cem\u003eI know you\u0026rsquo;re smart and you\u0026rsquo;ve studied for your Canadian exams\u0026hellip;\u003c/em\u003e\u0026rdquo;, their current gaps \u0026ldquo;\u003cem\u003eyour patient management skills are going to be lagging\u0026hellip;and that\u0026rsquo;s ok\u0026hellip;\u003c/em\u003e\u0026rdquo;, and a roadmap of the next few months- \u0026ldquo;\u003cem\u003ethe goal is by six months you are in step with your average Canadian graduate\u003c/em\u003e\u0026rdquo; (Table 3, Row 2, Column 3, Pa17).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA few C-IMG participants in our return of findings had discrepant experiences when shown \u003cem\u003ehiding in plain sight.\u003c/em\u003e These participants still resonated with the internalized perception of a stigma prior to entering residency, however, they had positive and re-enforcing experiences of attending support in their residencies from the beginning, and thus, did not experience a need to hide their status or feel that their learning opportunities were impacted. Resident Participant 10 described their program director setting the tone on their first day of residency, which helped diminish perceived stigma: \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;She was very, very encouraging...I can remember her saying things like, being an IMG is an asset, you\u0026apos;re some of our strongest residents\u0026hellip;now that you\u0026apos;re in the program, there is no IMG or [Canadian graduates], now we\u0026apos;re all [name of University] residents\u0026rdquo; (Pr10, return of findings focus group).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBoth C-IMG and attending participants had several ideas about how to create an ideal \u003cem\u003e\u0026ldquo;environment for success\u0026rdquo;\u003c/em\u003e (Pa16) for C-IMGs.\u0026nbsp;As described in the above sections\u003cem\u003e,\u003c/em\u003e C-IMG participants highlighted that their needs were different from I-IMGs, and thus, programs should have dedicated interventions for their cohort. As summarized in [Table 3] Columns 1 and 2, participants identified several interventions that can be instituted pre-residency and during residency to help support C-IMGs.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eDespite the number of trainees globally who pursue medical education abroad and return to their home countries for postgraduate training, little is known about their unique integration experiences and support needs (7, 16, 18). The purpose of this study was to explore one such group, IM C-IMGs and their integration experiences, to gain insights into ways to improve their transition back to residency programs in their home country. Building on prior research, our study identifies experiences unique to this group of IMGs (7, 14, 15). More compelling, however, were new insights around the perceived need, for many to \u003cem\u003ehide in plain sight\u0026nbsp;\u003c/em\u003eand the impact of this in relation to the common experiences of the \u003cem\u003ecritical period of growth\u0026nbsp;\u003c/em\u003eand its long-term consequences. Our findings also contribute ways to better support them in their residency journeys. Although our study is specific to the Canadian context, lessons learned can inform international programs that accept trainees who return to their home country for postgraduate training.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThroughout the residency experience, nearly every participant described a \u003cem\u003ecritical period of growth\u003c/em\u003e that C-IMGs had to endure until they had caught up with their Canadian graduate peers. During this, their struggles and associated negative feelings were largely hidden from others. Perceived stigmatization and a desire to “blend in” with peers have been described by IMGs and other minoritized groups in residency (7, 28-30). What distinguishes the C-IMG experience is that, in many cases, they are able to successfully do so, sometimes at the expense of receiving support and engaging in learning opportunities (15). Social identity theory suggests that individuals derive their self-concept from group membership, with different identities becoming salient depending on context (31, 32). Members of marginalized groups may suppress or conceal aspects of their identity to navigate dominant workplace cultures (32, 33). Retrospectively, this framework is relevant when considering our findings: C-IMGs share national identity with Canadian graduate peers but differ in educational pathways, creating tension around which identity is more salient (16, 32). To resolve this tension and to belong to the in-group, some C-IMGs tried to conceal their IMG identity (16, 31). It is not surprising that this concealment at a time when the C-IMGs described they were struggling, led to \u003cem\u003elingering effects\u003c/em\u003e-including feelings resembling impostor syndrome- that persisted for years and may have prolonged or disrupted identity formation (28, 32, 34, 35). If, as we believe, this experience is shared by many C-IMGs, there is a pressing need to change how we support C-IMGs from undergraduate to postgraduate training.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eKey to the creation of -what one participant coined- “\u003cem\u003ean environment for success”\u003c/em\u003e to diminish the C-IMGs’ perceived need to hide is authentic mentorship (Table 3, Row 3) (36). This could reduce stigmatization and allow for open acknowledgement of the C-IMG training status and unique journey. \u0026nbsp;However, implementing this both sensitively and meaningfully would require significant faculty development to help supervisors better understand the C-IMG experience and have strategies for exploring this with their C-IMG trainees in an individualized way. It would also require setting up, especially in early residency, check-ins between faculty and C-IMGs to allow for this to unfold in supportive ways with, as necessary, the discussion of tools and strategies (7, 19). Another identified strategy that is supported by prior research would be vertical near peer mentorship programs (7), which can be a place where residents feel safe asking questions and feel validated that their experience is one that others have also been through. If successful, this could help foster an environment where C-IMGs feel supported and valued, diminish the need to hide, shorten the time it takes to \u003cem\u003ecatch up\u003c/em\u003e with their peers, and mitigate emotional consequences. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBeyond mentorship, participants also suggested other program-level recommendations that could potentially soften the \u003cem\u003eemotional toll\u003c/em\u003e of the \u003cem\u003ecritical period of growth\u0026nbsp;\u003c/em\u003ethat C-IMGs experience (Table 3, Column 3)\u003cem\u003e.\u0026nbsp;\u003c/em\u003eAlthough many participants described the importance of orientation bootcamps and clinical skills workshops (7, 9), they also emphasized intentional and mindful scheduling by programs. Consistent with prior research (7, 15), all participants advocated against assigning C-IMG overnight call duties before they had received adequate daytime orientation to clinical workflow. Such scheduling practices may inadvertently intensify feelings of inadequacy and reinforce concealment behaviours during the vulnerable early residency period.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThere are important pre-residency considerations that also warrant attention (Table 3, Column 3). Similar to existing literature, C-IMGs in our study who did an intern year abroad, or participated in Canadian electives before residency reported a smoother transition than those without such experiences (7). While they experienced many similarities in their transition, what was different was that they had a prior experience working as part of a team to participate in patient care duties instead of purely observing (15, 17). This led us to ask whether undergraduate programs should be encouraged to provide these types of pre-residency opportunities to their students seeking residency in Canada (14, 18). Once accepted to residency, resident and attending participants in our study wondered if a pre-residency transition program with graduated clinical experience (similar to programs offered for I-IMGs in some institutions) could be helpful for C-IMGs (14, 37). However, such programs must be designed carefully to ensure C-IMG recruitment equity (38) and balance “othering” of C-IMGs in early residency (7, 30), as the intent would be to diminish, not exacerbate negative feelings.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study has several noteworthy limitations. While we attempted to recruit a range of participants from various Canadian IM programs and international undergraduate schools, not all C-IMG journeys were captured in our study. Thus, transfer to other settings may require further contextualization. While our findings were focused on C-IMGs, and while hiding in plain sight is likely quite unique to them it is possible that several IMGs may share similar experiences to participants in our study; this could be explored in future research. Similarly, while we studied Canadians studying abroad and returning to Canada, other IMGs who are returning for residency to their home country warrant study as well. Participants were not purposefully sampled based on gender, race, or cultural factors. However, we are mindful that C-IMGs hold numerous personal identities at once (39, 40), and these intersecting factors may contribute to social identity and feelings of self-doubt, thus, they are important considerations for future research (32, 41).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAs in Canada (7, 20), IMGs who study abroad and return to their home country for residency are an important and valued part of many countries’ physician workforce (4, 6, 20). Focused on the Canadian context, we provide novel insights into their experiences integrating into residency and practical recommendations for supporting these trainees, emphasizing the role of authentic mentorship to foster visibility of training status, validation of their challenging journey and individualized guidance. IMGs of all types face significant challenges in their journey returning to their home countries for residency, and those adversities do not stop upon acceptance to a postgraduate program (7, 15, 18). We encourage educators internationally to identify whether IMGs or similar trainees are ‘\u003cem\u003ehiding in plain sight’\u0026nbsp;\u003c/em\u003ein their programs, adapt these recommendations and measure impact. Further, we call for broader research on the topic of IMGs returning to their home countries for residency.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/em\u003eThis study was approved by the Research Ethics Board at Western University, Ontario, Canada (REB #121311). Written informed consent was obtained from all participants prior to their interviews. All methods were carried out in accordance with the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans (TCPS2).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication:\u0026nbsp;\u003c/em\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of Data and Materials:\u003c/em\u003e The datasets generated during this study are not publicly available to protect participant confidentiality. Reasonable requests for information can be directed to the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting Interests:\u003c/em\u003e Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors Contributions:\u0026nbsp;\u003c/em\u003eZ.M conceived the study and developed the research question, designed the study methodology and interview guide with the input of K.A.B, J.T and M.G. Z.M and K.A.B recruited participants and Z.M conducted all interviews. Z.M led the data analysis using constructivist grounded theory methodology. K.A.B, J.T and M.G provided methodological oversight and participated in iterative data analysis and thematic development. Z.M drafted the initial manuscript. K.A.B, J.T, and M.G provided critical revisions for important intellectual content. All authors read and approved the final manuscript and agree to be accountable for all aspects of the work.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding/Support:\u0026nbsp;\u003c/em\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eUse of Artificial Intelligence:\u003c/em\u003e The authors used generative AI models [GPT-5, Microsoft Copilot, Claude (Anthropic)] for language editing and manuscript organization during the preparation of this work. The tools were used to refine the abstract and to improve clarity and flow for certain challenging sentences in the introduction, methods, results and discussion. No confidential or unpublished data were entered into the AI systems. All AI-generated content was thoroughly reviewed, edited and verified by the authors, who take full responsibility for the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePrevious Presentations:\u0026nbsp;\u003c/em\u003eThe abstracts of earlier versions of this article were presented at the International Congress on Academic Medicine 2024 and International Conference of Residency Education 2024. \u003cstrong\u003e\u003cu\u003e\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCronin F, Clarke N, Hendrick L, Conroy R, Brugha R. The impacts of training pathways and experiences during intern year on doctor emigration from Ireland. Hum Resour Health. 2019;17(1):74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAhmed AA, Hwang WT, Thomas CR Jr., Deville C. 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Selection of international medical graduates into postgraduate training positions in Canada. Who applies? Who is selected? Canadian Medical Education Journal; 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMonrouxe LV. When I say\u0026hellip; intersectionality in medical education research. Med Educ.2015;49(1):21\u0026thinsp;\u0026ndash;\u0026thinsp;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCrenshaw K. Demarginalizing the Intersection of Race and Sex: A Black Feminist Critique of Antidiscrimination Doctrine, Feminist Theory and Antiracist Politics. Univ Columbia. 1989;139.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLaDonna KA, Ginsburg S, Watling C. Rising to the Level of Your Incompetence: What Physicians' Self-Assessment of Their Performance Reveals About the Imposter Syndrome in Medicine. Acad Med. 2018;93(5):763\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 2. Representative Quotes from Participants\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"671\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 671px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRepresentative Quotes Related to Critical Period of Growth and Catching Up\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 671px;\"\u003e\n \u003cp\u003e\u003cu\u003eDifferences in Undergraduate Training\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;...\u003c/em\u003e\u003cem\u003emore of an observership. You\u0026apos;re not really putting in orders. You\u0026apos;re not really contributing very much to patient management. Your goal is to be present. Observe, learn by osmosis, and then carry out physical examinations and histories and present them, but not really to take responsibility for patients to the same extent that our medical students would be doing here.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Pr12).\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 671px;\"\u003e\n \u003cp\u003e\u003cu\u003eCatch Up Period\u003c/u\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;As I went through more CTU rotations, I very much learned by\u0026hellip;modeling. So, it was seeing more senior residents and how they do things, seeing more of how the other co-residents do things and just picking up on those things and adding those to my day to day and that made me feel more comfortable... by the time I got to my second set of [CTU] rotations, which is\u0026hellip;midway through the year, I felt more comfortable, which is what people usually say happens. And then it was the positive feedback along the way from staff supervisors. And that really helped me feel a little bit more comfortable and realize that I deserve to be there\u0026hellip;You know, I was doing an okay job.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Pr8).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 671px;\"\u003e\n \u003cp\u003e\u003cu\u003ePhase of Disorientation\u003c/u\u003e\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;\u003cem\u003eI had no prior exposure to the [CTU] here prior to starting\u0026hellip;and we had received training online for how to use the [electronic medical record] on how to write a [consult] note... but I had never received hands on training\u0026hellip; so I remember my first night shift\u0026hellip;I did not know how to do anything. I had to rely on the [final year] medical student to help me figure out where to find stuff on [the computer], how to order stuff, how to get around even and what my job is really like\u0026hellip;what my responsibilities are.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Pr3).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 671px;\"\u003e\n \u003cp\u003e\u003cu\u003eMaking Clinical Decisions\u003c/u\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I found that a lot of the other residents were like, okay, [I think this patient has pneumonia] - maybe [let\u0026rsquo;s start] Ceftriaxone, Azithromycin, [a litre] of [normal saline], you know, it was kind of like they knew the [exact] steps where my knowledge base was mainly\u0026hellip; [let\u0026rsquo;s start] some form of antibiotics and fluids and basic blood work at some time intervals. But I feel like they had a lot of those detailed steps down like way earlier than I did.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Pr7).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 671px;\"\u003e\n \u003cp\u003e\u003cu\u003ePrematurely Asking for Help\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I think on one of my first few days, my patient [had] tachycardia\u0026hellip;I escalated it to my [senior medical resident] \u0026hellip;right away before\u0026hellip;[I] had literally done anything. And I think\u0026hellip;they said that, you know, that\u0026rsquo;s great\u0026hellip;maybe \u0026hellip;do these simple tests [first]. And I [realized], [I]\u0026hellip;had known, I knew how to do that. But I was so nervous... Just seeing whatever that clinical presentation was [for the first time].\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Pr2).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 671px;\"\u003e\n \u003cp\u003e\u003cu\u003eDelayed Seeking Help\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;At the start\u0026hellip;it gave me a bit of paralysis\u0026hellip;I think it did get in the way\u0026hellip;I would think all my [Canadian graduate peers] already know this, so I should be expected to know\u0026hellip;this is just something that I\u0026rsquo;ll take on myself and figure it out on my own because it would be telling if I revealed that I didn\u0026rsquo;t know this. So, there was some anxiety around that.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Pr8).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 671px;\"\u003e\n \u003cp\u003e\u003cu\u003eIntern Year Prior to IM Residency\u003c/u\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;You\u0026rsquo;re observing a lot, and you would see how care plans are being advanced, and you would write the discharge summaries\u0026hellip;so you participate actively in [patient] care, but you\u0026apos;re never making a decision by yourself and you\u0026apos;re never going and assessing a patient really by yourself during the day\u0026hellip;\u0026rdquo; (Pr10).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 671px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRepresentative Quotes Relating to Emotional Toll and its Lingering Effect\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 671px;\"\u003e\n \u003cp\u003e\u003cu\u003eEmotional Toll\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;\u003cem\u003eI had a call shift, the second day of my training, and I was carrying three pagers for three different teams. And I just felt completely overwhelmed. The pager went off for me to see a patient\u0026hellip;and so I left the\u0026hellip;call room and I was walking towards\u0026hellip;trying to find this room and ended up getting lost in the basement of the hospital. And I\u0026hellip; just burst into tears\u0026hellip; I found a bathroom and just basically cried because I was like, so flustered and I felt so like useless. Like, I didn\u0026apos;t even know where to go. And I just felt completely overwhelmed.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Pr5).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 671px;\"\u003e\n \u003cp\u003e\u003cu\u003eLingering Effect\u003c/u\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Now I feel on par\u0026hellip;But it\u0026apos;s taken years to get here. I never felt on par in residency [when I was a C-IMG]. I remember getting feedback once from [a] really an excellent IM attending\u0026hellip;he pulled me aside in my PGY3 year and he said\u0026hellip; you probably get this all the time, but you\u0026apos;re the strongest resident I\u0026apos;ve ever worked with.\u003c/em\u003e \u003cem\u003eAnd I remember going, I don\u0026apos;t know what you\u0026apos;re talking about. I feel like I\u0026apos;m so weak.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Pa17).\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 671px;\"\u003e\n \u003cp\u003e\u003cu\u003eSkewed Frame of Reference\u003c/u\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;It was one of my first shifts and I got\u0026hellip;I think 28 consults that came in \u0026hellip;and I had to stop it at consult number 16 by 5 a.m.\u0026hellip;I took that on as like I had failed ...It was my own personal flaw \u0026hellip;it wasn\u0026apos;t until a while later of going through night float and figuring out how things go and what is reasonable for my level and talking to other people that I was able to\u0026hellip;get over that.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Pr8).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePGY3= post-graduate year 3\u003c/p\u003e\n\u003cp\u003eCTU= Clinical Teaching Unit\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"709\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 709px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 3. Participant and Research Team Suggestions with Representative Quotes around Creating an Environment to Support IMGs, Including C-IMGs\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuggestions by Participants\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 331px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRepresentative Quotes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eResearch Team Suggestions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 709px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-Residency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eCanadian electives during undergraduate years\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eShadowing experience\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eGraduated patient care responsibilities\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 331px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I got to see\u0026hellip;what the Canadian medical students were doing and the residents and see what the expectations were. So, by the time I came in on July [1st], even though maybe I hadn\u0026apos;t had as much experience, I knew [what] was going to be a deficit.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Pr2).\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;If you could\u0026hellip;shadow or something more practical\u0026hellip;follow around one of the junior residents\u0026hellip;for a couple of days\u0026hellip;see what the patient load is\u0026hellip;I would have loved to do that.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Pr4).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003ePrior to residency, consider opportunities such as Intern year or Canadian electives.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eProvide opportunities for IMGs to actively participate in low-stakes clinical activities before or at the beginning of residency to learn the expectations as first-year residents, such as their role and clinical responsibilities.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 709px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuring Residency\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026agrave;\u003c/strong\u003e\u003cstrong\u003eMitigating Disorientation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eThoughtful scheduling of IMG residents\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eBootcamp at the start of residency\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003ePGY1 handbook\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eIterative feedback from residents\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eIMG workshop\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 331px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Not being put on call July 1st would have been so huge for me\u0026hellip;and even graduated call or call the second week so that you at least have a sense of how things work\u0026hellip; it just adds to the feeling of being super overwhelmed if you\u0026apos;re just thrown into a 26-hour shift and you have no idea what\u0026apos;s going on\u0026hellip;I don\u0026apos;t know if it would be helpful or not helpful to be starting [residency] on CTU and to this day I still don\u0026apos;t know.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Pr4).\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip; we had a focus group with all our C-IMGs and I-IMGs, this is where our bootcamp was born out of\u0026hellip;. the residents are saying hey this is an issue this is relevant to us\u0026hellip;And that\u0026apos;s the way we\u0026hellip;developed a lot of this in the last 2 years\u0026hellip;.and we also see that through our quality improvement process\u0026hellip;\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Pa18).\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;You can have a -very non-judgemental- workshop, create a [safe environment], to get to know [C-IMGs] better, see if they think\u0026hellip;hey, I would like to develop more in this area\u0026hellip;bring cases\u0026hellip;share tips.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Pa14).\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePrograms should engage in intentional and mindful scheduling of IMGs, especially when considering overnight call duties, first rotations and burnout.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eA residency orientation handbook and \u0026ldquo;bootcamp orientation\u0026rdquo; should be provided to all residents, including IMGs. Other interventions such as an IMG or specific I-IMG and C-IMG workshop(s) can be considered.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eAll program interventions should undergo iterative feedback by IMGs and other stakeholders.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 709px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuring Residency\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026agrave;\u003c/strong\u003e\u003cstrong\u003eAuthentic Mentorship\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eMaking sure rotation leaders and attendings are aware of IMG learning needs\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eAuthentic mentorship\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eFrequent Check-ins\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003ePeer mentorship with other C-IMGs\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 331px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Correct placement and orientation of the people who are in power positions and their supervisors.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Pa17).\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Making sure each attending is fully aware of what their [C-IMG resident] is coming with and what they need.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Pa16).\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003cem\u003eI\u0026hellip;started to realize that my feelings and just [the] huge learning curve and adjustment was not just specific to me and that other people experienced it\u0026hellip;[my attending] really validated my feelings and she herself was not an IMG but she said a lot of her colleagues were, and that they were excellent physicians and she knew for a fact that they also cried their first summer \u0026hellip;.I feel like it was like it was almost more her than me, to be honest in terms of initiating that conversation.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Pr4).\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I sit down with [C-IMGs] and say, look, you probably have great clinical skills. I know you\u0026rsquo;re smart and that you\u0026rsquo;ve studied for the Canadian exams \u0026hellip;but your patient management skills are going to be lagging because you just haven\u0026rsquo;t done that before...and that\u0026rsquo;s okay, it\u0026rsquo;s not okay to stay where you are. I\u0026rsquo;m going to push you in a graduated fashion. And I\u0026rsquo;m going to suggest resources for you. And the goal is by six months you are in step with your average Canadian graduate when it comes to patient management skills. That includes things like requestions and paperwork, facilitating family meetings, discharge summaries, writing a prescription. And importantly\u0026hellip;making decisions with a healthy degree of initiative and testimony.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Pa17).\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Regular check ins about how we\u0026apos;re doing\u0026hellip;having set objectives to work on efficiency.\u0026rdquo; (Pr8).\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;to have somebody a year ahead of you who is a C-IMG, [who you can] discuss [with] and get help from, on a day-to-day basis\u0026hellip;even having a road map of what the new year of residency will hold for you.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Pr5).\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eAll attendings that have the potential to supervise an IMG should be primed about a typical I-IMG and C-IMG\u0026rsquo;s educational journey prior to residency, the challenges they experience and their unique learning needs.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eConsider pairing an IMG with an experienced and motivated mentor who is separate from their supervisor, to have frequent check-ins about the IMG experience navigating residency.\u003c/p\u003e\n \u003cp\u003ePrograms should be mindful that attendings who are supervising IMGs at the start of residency are experienced in working with struggling learners. These attendings should be encouraged to have frequent feedback sessions with the IMG, ensuring to reconcile their feedback with the IMG\u0026rsquo;s self-assessment and to openly discuss challenges and next steps.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFacilitate a network of vertical near-peer mentors (such as senior residents from the same program) who can be vulnerable and transparent about initial challenges and provide support to C-IMGs. This mentorship should start before residency and persist past post-graduate year 1.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations: C-IMGs= Canadian-International Medical Graduates; CTU= Clinical Teaching Unit, I-IMGs= Immigrant-International Medical Graduates; IMG= International Medical Graduate\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"International medical graduates, postgraduate education, Canada, Internal medicine, qualitative research, imposter syndrome","lastPublishedDoi":"10.21203/rs.3.rs-8585367/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8585367/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eInternational Medical Graduates (IMGs) comprise a large share of the global medical workforce and often face challenges integrating into residency, even when returning to their country of citizenship. These needs remain poorly understood, limiting programs\u0026rsquo; ability to provide targeted support. In Canada, such physicians\u0026mdash;Canadian citizens trained abroad (Canadian-IMGs) encounter similar barriers in Internal Medicine (IM) residency. The purpose of this study was to explore the integration experiences of IM C-IMGs.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eUsing constructivist grounded theory, we conducted semi-structured interviews with IM Canadian-IMGs and program directors/faculty across Canada. Consistent with our methodology, we used constant comparison and iterative cycles of data collection and analysis. Data were collected until theoretical sufficiency was achieved.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eNineteen participants were interviewed between January 2023 and April 2024: 12 Canadian-IMGs and seven faculty. A hallmark finding was a perceived need by participant Canadian-IMGs to \u0026lsquo;hide in plain sight\u0026rsquo; and keep their training background hidden, at the sacrifice of requesting support. Participants also described a \u0026lsquo;critical period of growth\u0026rsquo;, that Canadian-IMGs navigated when starting residency, characterized by the early personal recognition of a gap between their strong theoretical but minimal practical knowledge. As a result, some resident participants also described a \u0026lsquo;lingering effect\u0026rsquo; of self-doubt that persisted well beyond first year.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eWhile focused on the Canadian context, this study adds novel insights into the experiences of citizens who study abroad and return to their own country for residency training. In particular, some residents intentionally hid their IMG status, but this came at a cost, often with long-term consequences. We identified several strategies to visibly acknowledge their journey and offer supports such as through authentic mentorship. Findings may inform international programs with IMGs who have returned to their home countries for postgraduate training.\u003c/p\u003e","manuscriptTitle":"Title: ‘Hiding in Plain Sight’: A Qualitative Study of International Medical Graduates Returning to Their Home Country for Internal Medicine Residency","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-11 16:38:30","doi":"10.21203/rs.3.rs-8585367/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-02-26T12:05:50+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-16T19:53:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"254765853282568970118616779155300543373","date":"2026-02-13T15:41:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"123270622316521748452834565688087000842","date":"2026-02-12T10:44:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"39652294465515015853930341815732860355","date":"2026-02-08T16:36:09+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-06T10:56:09+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-19T11:58:34+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-17T11:33:16+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-17T11:31:08+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2026-01-12T21:19:04+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ff766067-d96c-4ea6-be80-fc8be792796e","owner":[],"postedDate":"February 11th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-11T16:38:31+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-11 16:38:30","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8585367","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8585367","identity":"rs-8585367","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}