PowerPoint Presentation

Inge SchabortMcMaster University, IMG Pre-Residency IMG Program

Plenary IV: Research on Impacts and Outcomes

Plenary IVResearch on Impacts and OutcomesTouchstone Symposium:Perspectives on Successful Transitions for Internationally Educated Health Professionals.

Dr Inge Schabort MB ChB CCFP FCFPAssociate Professor, IMG CoordinatorMcMaster University

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ConflictsI am an IMG None otherSchabort

ObjectivesChronological tour of Ontario IMG literature and researchA few significant IMG outcome research studiesSchabort

Dealing with Discrimination

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Human rights tribunal ruled against 5

Ontario commissioned Thomson and Cohl Judicial reports 201133 recommendations Most recommendations accomplished since

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http://www.health.gov.on.ca/en/common/ministry/publications/reports/thomson/v1_thomson.pdfSchabort

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Thomson Working Group Struck33 recommendations worked through since 2011Schabort

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The selection of international medical graduates to residency programsWhat selection information best predicts success at college certification exams?

Inge Schabort, Sharon Cameron & Lawrence GriersonSchabort

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BackgroundDue to the physician shortage, more IMGs than ever before are admitted to residency programs in Canada.

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March 2010: 1916 IMGs in postgrad training in Canada. (FMEC PG)

The failure rate for IMGs in the end of residency College exams is significantly higher than for Canadian medical school graduates. Many IMGs also need remediation during residency.

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COLLEGE EXAM PASS RATE(FMEC IMG report)FAMILY MEDICINE YEARCMGIMG residency trained200790.4%66.0%200874.0%200964.0%201051.0%

ROYAL COLLEGE PRIMARY SPECIALTY EXAMS first attemptYEARCMGIMG2005-200996%75%

Walsh A, Banner S, Schabort I, Armson H, Bowmer I, Granata B. International Medical Graduates - Current Issues. Members of the FMEC PG consortium; 2011.

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Limited information is available about which factors available to us at the time of the CaRMS selection, can serve as predictors for success during residency training.

Tools that could assist with the selection of the IMG candidates most likely to succeed during postgraduate training in Canada are needed.

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Literature Review

IMG Predictors for SuccessAge (Kanna 2009) Time since medical school graduation(Bates 2001), (Bates 2000), (Bessant 2006) Recent clinical experience (Part and Markert 1993) Performance on Standardized exams (Kanna 2009)( Part and Markert 1993), (Shiroma 2010),(Perez 2009)Variable undergraduate education amongst IMGs (Van Zanten and Boulet 2008)English Language proficiencyDoing a clerkship in Canada before residency (MacLellan 2012)

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Although there has been NO comprehensive effort i.e., across factors and institutions - to determine the true predictive value of these factors.

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More predictorsMedical School attendedCountry of training as predictor for college complaintsSchabort

HypothesesAge; Time since graduation/last practice (Kanna, 2009; Bessant, 2006)

Language and Cultural Difficulties (Bates, 2000; 2001)

Differences in medical education (vanZanten & Boulet, 2008)

Professional Experience (clinical, internship, research) (MacLellan, 2012)Schabort

SO we grouped the predictors into hypotheses

Although the results of our investigation are presented in light of some of the popular hypotheses, because these positions are often generated on anecdotal evidence this work can be best thought of as a hypothesis generating exercise.

For example, while it may be sufficient to identify age as an important factor in IMG success, it is more relevant to know why age is a factor.

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PurposeAs a first step in untangling the various proposed factors/mechanisms that impact IMG certification success this study reports the information that is available to the McMaster University residency program at the time of the Canadian Residency Matching Service (CaRMS) that predicts IMG success at the college certification exams.Schabort

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MethodsLinear and logistic regression analyses determined the degree to which the information available at the time of residency selection predicts the performance of McMaster University IMG residents on the CFPC (n = 69) and RCPSC (n = 85) certification examinations between 2005 and 2011.

Regression models accounted for: Demographics (age, nationality, first language) Education (country of medical schooling, years since graduation)Experience (internship, residency, professional, research)

MCC-EE scores were correlated with certification exam scoresSchabort

Mention the HDI Index here20

ResultsDemographic Factors

CFPC IMGs that do not speak English as a first language performed about 4 points better on the SOOs, = 4.4, p = .05.

CFPC IMGs born outside of Canada did about 3.5 points better on the SAMPS than Canadians who studied abroad, = 3.4, p = .049.

Although not significant, age was a negative predictor for CFPC IMGs, odds ratio = .86, p = .122, and RCPSC IMGs, odds ratio = .84, p = .13. With each year older, CFPC IMGs and RCPSC IMGs were 14% and 16% , respectively, less likely to pass their overall certification exams.

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Key point AGE

Nationality and First Language had relatively small effects w/rr/t/ actual impact.21

ResultsEducation Factors

For every unit increase of the Human Development Index of the country of medical schooling, CFPC IMGs' scores on the SOOs increased by 18 points, = 17.8, p = .046.

Years since graduation was not a significant predictor

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Key Point Schools in some countries are better than others. - Years since graduation was NOT a factor.22

ResultsExperience Factors

For CFPC IMGs, professional experience had a significant negative relationship with outcomes on the Simulated Office Orals (SOOs), = -5.1, p = .042, and Short Answer Management Problems (SAMPS), = -4.4, p = .045.

RCPSC IMGs that participated in a previous internship increased their odds of passing the RCPSC certification exam by 4 times; odds ratio = 4.1, p = .02.

The impact of professional experience on CFPC IMGs overall CFPC Certification outcomes wasn't significant. However, the analysis does indicate that those with professional experience were approximately 60% more likely to be unsuccessful, odds ratio = .39, p = .18.

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Key Point The role of previous experience is differential depending on the medical specialty at least at the distinction of family physician and specialist. 23

ResultsMCC-EE scores were positively correlated with CFPC IMGs performances on the SAMPS (r = .481, p < .001) and overall certification success (r = .317, p = .018) as well as RCPSC IMGs certification success (r = .264, p = .027).

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Key point - As we know performance predicts performance; so this isnt terribly surprising. Yet MCC-EE scores are accounting for only around 30% of the varianceneed to look deeperat QE1 and QE2 scores.

Lowest Passing Scores RC (260); CF (254)24

Narrowing the HypothesesAgeAge-related decline or associated factors?

Differences in Medical EducationWhich Schools in which Countries?Normalizing Transcriptsan HDI by transcript algorithm?

The Role of Previous ExperienceThe cultural implications of practice experience?

And the seemingly less relevantTime Since Medical School GraduationLanguage Difficulties

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Age (regardless of years since graduation/last practice)

Age-related decline

Age-related factors (i.e., financial and family responsibility)

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Limitations and/or Next StepsSingle Institution Data SetCollaborative data analysis across institutions

Limited Test dataMCC inclusion of QE1 and QE2 scores REB approval has just been obtained

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Research just completed-first manuscript draft writtenPredictors for success in College exams IMGs in all Ontario Medical Schools CCFP as well as RCPS programs 2005 to presentData sharing agreement created amongst all 6 Ontario medical schools

Royal College Grant funded

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Accepted for publication. Chapter about Female IMGs in CanadaBook: Women in Medicine 2017Schabort

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Surveys of IMGs -Themes identified

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Schabort, Cervin, BandieraBest Practices in selection of IMGs and CMGs survey from COFM to all Program Directors of All programs CFPC as well as Royal College re selection practices 1st and 2nd iteration of CaRMS match

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MMI and professionalismHoffmeister found that there is evidence that the MMI offers a reliable and valid assessment of professionalism in IMG doctors applying for Canadian family medicine residencies and that this clinically situated MMI assessed facets of competency other than those assessed by the OSCE.

MMIsMMIs have several strengths: they can be designed to best fit relevant competencies, e.g. teamwork, communication skills. Studies suggest that MMIs are a reliable measure of non-cognitive attributes such as empathy, cultural sensitivity, advocacy and communication skills which are all important attributes for a doctor which can be observed in a specific context. Inferences may be made that MMIs help to protect patient safety as candidates are being observed and rated on doing a work sample.

MMI better predictor than OSCEEva et al. (2004b) and Reiter et al. (2007) found MMIs to be a better predictor of performance on OSCEs than more established methods of selection (e.g. GPAs and traditional interviews). MMIs cannot be coached for as there is not one formulaic answer and therefore security breaches in the selection process would not affect the performance of the candidate (Reiter et al., 2005 and Griffin et al., 2008).

MMI CostsMMIs are initially costly and time consuming to set up in terms of person hours and expense (e.g. development of the blueprint of competencies and scenarios, training the raters/interviewers and hiring the number of rooms required for the stations). However the value in terms of the reliability and validity over more traditional unstructured interviews may outweigh these initial costs.

Computer based non-cognitive pre-interview testDore et al explored the development of a non-cognitive pre-interview screening test that correlates with the well-validated MMI and performs multiple sample evaluation of non-cognitive skills (CMSENS) .This has possible future implications for IMG evaluation eg. to be administered remotely using the computer platform currently used for eg the MCCEE where the IMG can perform the assessment at any of the multiple sites outside of Canada.

However

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Questions?ischabo@mcmaster.caSchabort

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Graduate Medical Education. Journal of American Medical Association , 298(9):1081-1096.Brown, C., Wakefield, S., & Bullock, A. (2003). The Selection of GP trainees in the West Midlands: Second Audit of Assessment Centre Scores by Ethnicity and Country of Qualification. Medical Teacher , 25 (6) 649-653.Cartwright CA, Korsen N, Urbach LE. (2002) Teaching the Teachers: Helping faculty in a family practice residency improve their informatics skills. Acad Med May;77(5):385-91.Chamberlain, T.C., Catano, V.M. & Cunningham, D.P, (2005). Personality as a predictor of professional behavior in dental school: comparisons with dental practitioners. Journal of Dental Education. 69(11), pp.1222-37. Chamorro-Premuzic, T., Furnham, A. & Ackerman, P.L., (2006). Incremental validity of the typical intellectual engagement scale as predictor of different academic performance measures. Journal of Personality Assessment. 87(3), pp.261-8.Dirschl, D., Dahners, L., Adams, G., Crouch, J., & Wilson, F. (2002). Correlating Selection Criteria with Subsequent Performance as Residents. Clinical Orthopaedics and Related Research , 399:265-271.Dore, K. L., Reiter, H. I., Eva, K. W., Krueger, S., Scriven, E., Siu, E., et al. (2009). Extending the Interview to All Medical School Candidates - Computer-Based Multiple Sample Evaluation of Noncognitive Skills (CMSENS). Academic Medicine, 84:10 pp S9-S12.Eva, K., Reiter, H., Rosenfeld, J., & Norman, G. (2004). The ability of the multi-mini interview to predict preclerkship performance in medical school. Academic Medicine, 79(10 Suppl), pp. S40-2.Eva, K., Reiter, H., Rosenfeld, J., & Norman, G. (2004). The relationship between interviewers' characteristics and ratings assigned during a multiple mini-interview. Academic Medicine, 79(6), pp 602-9.Eva, K., Rosenfeld, J., Reiter, H., & Norman, G. (2004). An admissions OSCE: the multiple mini-interview. Medical Education, 38(3), pp.314-26.Ferguson, E., James, D., & Madeley, L. (2002). Factors Associated with Success in Medical School: Systematic Review of the Literature. BMJ , 324:952-7.Gayed, N. (1991). Residency Directors' Assessments of which selection criteria best predict the performances of foreign-born foreign medical graduates during internal medicine residencies. Acad Medicine, 66:699-701.Gonsalves, W., Wrightson, A., Love, M., & LJ, T. (2005). Practices and Perceptions of Family Practice Residency Directors towards International Medical Graduates: A National Survey. Retrieved March 25, 2010, from Med Educ Online: www.med-ed-online.orgGreen ML. (2000) Evidence-based medicine training in internal medicine residency programs a national survey. J Gen intern Med. Feb;15(2):129-33.Green ML, Ellis PJ . (1997) Impact of evidence-based medicine curriculum based on adult learning theory. J Gen intern Med. Dec;12(12):742-50.Griffin, B., Harding, D., Wilson, I., & Yeomans, N. (2008). Does practice make perfect? The effect of coaching and retesting on selection tests uses for admission to an Australian medical school. Med J. Aust, Oct 6;189(7):416.Hall P, Keely E, Dojeiji S, Byszewski A, and Marks M. (2004). Communication skills, cultural challenges and individual support: challenges of international medical graduates in a Canadian healthcare environment. Medical Teacher 26(2):120-125Hayden, S., Hayden, M., & Gamst, A. (2005). What Characteristics of Applicants to Emergency Residency Programs Predict Future Success as an Emergency Medicine Resident? Academic Emergency Medicine, 12 (3) 206-10.Hofmeister, M., Lockyer, J., & Crutcher, R. (2009). The multiple mini-interview for selection of international medical graduates into family medicine residency education. Medical Education, Volume 43, Issue 6 pages 573-579.Illing, J., Campbell, M., Kergon, C., Thompson, N., Burford, B., Morrow, G., et al. (n.d.). Selection Methods for Foundation Programme: A Literature Review. Retrieved November 14, 2010, from www.medschools.ac.uk/aboutus/projects/documents/appendix%20K%20Newcastle%20Literature%20Review.pdfKanna, B., Gu, Y., Akhuetie, J., & Dimitrov, V. (2009). Predicting Performance using Background Characteristics of International Medical Graduates in an inner-city University-Affiliated Internal Medicine residency training program. BioMed Central, 9:42.Korenstein D, Dunn A, McGinn, T. Mixing it up: Integrating evidence-based medicine and patient care. Acad Med Jul;77(7):741-2.Lee, A., Golnik, K., Oetting, T., Beaver, H., Boldt, H., Olson, R., et al. (2008). Re-Engineering the Resident Application Process in Opthalmology: A Literature Review and Recommendations for Improvement. Survey of Opthalmology , 53 (2) 164-176.MacLellan, A., Brailovsky, C., Rainsberry, P., Bowmer, A., & Desrochers, M. (2010). Examination outcomes for International Medical Graduates pursuing or completing Family Medicine Residency training in Quebec. Can Fam Physician, 56:912-8.McClintock, J., & Gravlee, G. (2010). Predicting Success on the Certification Examinations of the American Board of Anesthesiology. Anesthesiology , 112:212-9.Papadakis, M., G, A., Holmbee, E., & Lipner, R. (2008). Performance during Internal Medicine Residency Training and Subsequent Disciplinary action by Stat Licensing Boards. Annals of Internal Medicine , 148(11); 869-876.Part, H., & Markert, R. (1993). Predicting the first year performances of international medical graduates in an internal medicine residency. Acad Med, 68(11): 856-8.Perez JA, Greer ES. (2009) Correlation of United States Medical Licensing Examination and Internal Medicine In-Training Examination performance. Adv in Health Sc Educ 14;753-758Pilotto LS, Duncan GF and Anderson-Wurf J. (2007). Issues for clinicians training international medical graduates: a systematic review. Medical Journal of Australia; 187(4):225-228.Poole, A., Catano, V.M. & Cunningham, D.P. (2007). Predicting performance in Canadian dental schools: the new CDA structured interview, a new personality assessment, and the DAT. Journal of Dental Education. 71(5), pp.664-76. Posthuma, R., Morgeson, F., & Campion, M. (2002). Beyond Employment Interview Validity: A Comprehensive Narrative Review of Recent Research and Trends Over Time. Personnel Psychology , 55:1-81.Quintero, A., Segal, L., King, S., & Black, K. (2009). The Personal Interview: Assessing the Potential for Personality Similarity to bias the Selection of Orthopaedic Residents. Academic Medicine , 84:1364-1372.Rao, N., Meinzer, A., Primavera, L., & Augustine, A. (1991). Psychiatry Residency Selection Criteria for Maerican and Foreign Medical Graduates. Academic Psychiatry , 15:69-79.Reiter, H., Eva, K., Rosenfeld, J., & Norman, G. (2007). Multiple mini-interviews predict clerkship and licensing examination performance. Medical Education, 41 (4), pp 378-84.Ross R, Verdieck A. (2003) Introducing an evidence-based medicine curriculum into a family practice residency-is it effective. Acad Med Apr;78(4):412-7.Shiroma, P. R., & Alarcon, R. D. (2010). Selection Factors Among International Medical Graduates and Psychiatric Residency Performance. Academic Psychiatry, 34: 128-131.Shuval K, Berkovits E, Netzer D, Hekselman I, Linn S, Brezis M, Reis S. (2007) Evaluating the effect of an evidence-based medicine educational intervention on primary care doctors attitudes, knowledge and clinical behaviour:a controlled trial and before and after study. J Eval Clin Pract. Aug;13(4):581-98.Sierles, F., Daghestani, A., Weiner, C., de Vito, R., Fichtner, C., & Garfield, D. (2001). Psychometric Properties of ABPN Style Oral Examinations Administered Jointly by Two Residency Programs. Academic Psychiatry , 25:214-22.Smilen, S., Funai, E., & Bianco, A. (2001). Residency Selection: Should Interviewers by given applicants' board scores? American Journal of Obstetrics & Gynecology , 184:508-513.Szafran, O., Crutcher, R. B, Banner SR, & Watanabe, M. (2005) Canadian and Immigrant International Medical Graduates. Can Fam Physician. September 10; 51(9): 1243. Tamblyn, R., Abrahamowicz, M., Dauphinee, D., Wenghofer, E., Jacques, A., Klass, D., et al. (2007). Physician Scores on a National Clinical Skills Examination as Predictors of Complaints to Medical Regulatory Authorities. Journal of American Medical Association , 298 (9) 993-1001.Thordarson, D. E. (2007). Resident Selection: How are we doing and why? Clinical Orthopaedics & Related Research, 459: pp 255-9.Van Zanten, M., & Boulet, J. (2008). Medical Education in the Caribbean: Variability in Medical School Programs and Performance of Students. Acad Med, 83 (10 Suppl):S33-6.Van Zanten, M., Boulet, J., & McKinley , D. (2003). Correlates of Performance of the ECFMG Clinical Skills Assessment: Influences of Candidate Characteristics on Performance. Acad Med ,78(10):S72-74.Van Zanten, M., Boulet, J., McKinley, D., & Whelan, G. (2003). Evaluating the spoken English proficiency of international medical graduates: Detecting threats to the validity of standardised patient ratings. Med Educ, 37: 69-76 Wong A, Lohfeld L. (2008) Recertifying as a doctor in Canada: International Medical Graduates and the Journey from Entry to Adaptation. Medical Education 42(1): 53-60Yew Ks, Reid A. (2008) Teaching Evidence-Based Medicine Skills: an Exploratory Study of Residency Graduates Practice Habits. Fam med Jan;40(1);24-31.

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References ContinuedKorenstein D, Dunn A, McGinn, T. Mixing it up: Integrating evidence-based medicine and patient care. Acad Med Jul;77(7):741-2.Lee, A., Golnik, K., Oetting, T., Beaver, H., Boldt, H., Olson, R., et al. (2008). Re-Engineering the Resident Application Process in Opthalmology: A Literature Review and Recommendations for Improvement. Survey of Opthalmology , 53 (2) 164-176.MacLellan, A., Brailovsky, C., Rainsberry, P., Bowmer, A., & Desrochers, M. (2010). Examination outcomes for International Medical Graduates pursuing or completing Family Medicine Residency training in Quebec. Can Fam Physician, 56:912-8.McClintock, J., & Gravlee, G. (2010). Predicting Success on the Certification Examinations of the American Board of Anesthesiology. Anesthesiology , 112:212-9.Papadakis, M., G, A., Holmbee, E., & Lipner, R. (2008). Performance during Internal Medicine Residency Training and Subsequent Disciplinary action by Stat Licensing Boards. Annals of Internal Medicine , 148(11); 869-876.Part, H., & Markert, R. (1993). Predicting the first year performances of international medical graduates in an internal medicine residency. Acad Med, 68(11): 856-8.Perez JA, Greer ES. (2009) Correlation of United States Medical Licensing Examination and Internal Medicine In-Training Examination performance. Adv in Health Sc Educ 14;753-758Pilotto LS, Duncan GF and Anderson-Wurf J. (2007). Issues for clinicians training international medical graduates: a systematic review. Medical Journal of Australia; 187(4):225-228.Poole, A., Catano, V.M. & Cunningham, D.P. (2007). Predicting performance in Canadian dental schools: the new CDA structured interview, a new personality assessment, and the DAT. Journal of Dental Education. 71(5), pp.664-76. Posthuma, R., Morgeson, F., & Campion, M. (2002). Beyond Employment Interview Validity: A Comprehensive Narrative Review of Recent Research and Trends Over Time. Personnel Psychology , 55:1-81.Quintero, A., Segal, L., King, S., & Black, K. (2009). The Personal Interview: Assessing the Potential for Personality Similarity to bias the Selection of Orthopaedic Residents. Academic Medicine , 84:1364-1372.Rao, N., Meinzer, A., Primavera, L., & Augustine, A. (1991). Psychiatry Residency Selection Criteria for Maerican and Foreign Medical Graduates. Academic Psychiatry , 15:69-79.Schabort

References ContinuedGriffin, B., Harding, D., Wilson, I., & Yeomans, N. (2008). Does practice make perfect? The effect of coaching and retesting on selection tests uses for admission to an Australian medical school. Med J. Aust, Oct 6;189(7):416.Hall P, Keely E, Dojeiji S, Byszewski A, and Marks M. (2004). Communication skills, cultural challenges and individual support: challenges of international medical graduates in a Canadian healthcare environment. Medical Teacher 26(2):120-125Hayden, S., Hayden, M., & Gamst, A. (2005). What Characteristics of Applicants to Emergency Residency Programs Predict Future Success as an Emergency Medicine Resident? Academic Emergency Medicine, 12 (3) 206-10.Hofmeister, M., Lockyer, J., & Crutcher, R. (2009). The multiple mini-interview for selection of international medical graduates into family medicine residency education. Medical Education, Volume 43, Issue 6 pages 573-579.Illing, J., Campbell, M., Kergon, C., Thompson, N., Burford, B., Morrow, G., et al. (n.d.). Selection Methods for Foundation Programme: A Literature Review. Retrieved November 14, 2010, from www.medschools.ac.uk/aboutus/projects/documents/appendix%20K%20Newcastle%20Literature%20Review.pdfKanna, B., Gu, Y., Akhuetie, J., & Dimitrov, V. (2009). Predicting Performance using Background Characteristics of International Medical Graduates in an inner-city University-Affiliated Internal Medicine residency training program. BioMed Central, 9:42.

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