Is it really a challenge to find positive attributes for international medical graduates predictive of success in family medicine residency?

In their paper "Challenges with international medical graduate selection: finding positive attributes predictive of success in family medicine residency," (BMC Prim Care 23(256):2-9, 2022) the authors report on their research into qualitative attributes that positively correspond to success in residency with the objective of assisting in the selection of International Medical Graduate (IMG) residents most likely to achieve success in family medicine residency. The authors found that positive predictors of IMG residents' success were: presence of a positive attitude, proficient communication skills, high level of clinical knowledge, and trainability. The authors conclude that selecting IMG residents who possess these attributes will result in residents developing increased aptitudes for patient care. A careful reading of the paper raises a number of concerns. MacFarlane (Can Med Educ J 12(4):132-40, 2021) points out that IMGs are already marginalized in the residency selection process. Our concern is that this paper may contribute to this marginalization through a tone of negativity or bias against IMGs and the use of biased language throughout the paper that tends to cast IMGs as being inferior and somehow less well prepared for residency than Canadian Medical Graduates (CMGs). We argue that the proposed predictors are generic and equally relevant to both CMGs and IMGs. In focusing on these predictors in IMGs specifically, the paper appears to imply, without evidence, that IMGs are inadequate in the identified areas. After reviewing the paper's references, the existing literature, and an analysis of language used, we conclude that IMGs are capable candidates for residency, and that the qualitative attributes outlined in the paper offer little utility for the selection of IMG residents relative to CMG residents.

When a Canadian is not a Canadian: marginalization of IMGs in the CaRMS match.

This paper explores the marginalization experienced by International Medical Graduates (IMGs) in the Canadian Residency Matching Service (CaRMS) Match. This marginalization occurs despite all IMGs being Canadian citizens or permanent residents, and having objectively demonstrated competence equivalent to that expected of a graduate of a Canadian medical School through examinations such as the MCCQE1 and the National Assessment Collaboration OSCE. This paper explores how the current CaRMS Match works, evidence of marginalization, and ethnicity and human rights implications of the current CaRMS system. A brief history of post graduate medical education and the residency selection process is provided along with a brief legal analysis of authority for making CaRMS eligibility decisions. Current CaRMS practices are situated in the context of Provincial fairness legislation, and rationalizations and rationales for the current CaRMS system are explored. The paper examines objective indicators of IMG competence, as well as relevant legislation regarding international credential recognition and labour mobility. The issues are placed in the context of current immigration and education policies and best practices. An international perspective is provided through comparison with the United States National Residency Matching Program. Suggestions are offered for changes to the current CaRMS system to bring the process more in line with legislation and current Canadian value systems, such that "A Canadian is a Canadian."

Cet article explore la marginalisation vécue par les diplômés internationaux en médecine (DIM) dans le cadre du jumelage du Service canadien de jumelage des résidents (CaRMS). Cette marginalisation se produit en dépit du fait que les DIM concernés sont des citoyens canadiens ou des résidents permanents au Canada et qu'ils ont objectivement démontré une compétence équivalente à celle attendue d'un diplômé d'une faculté de médecine canadienne à des examens comme l'EACMC1 et l'ECOS de la Collaboration nationale en matière d'évaluation. L'article explore le fonctionnement actuel du jumelage du CaRMS, ses répercussions sur le plan de l'ethnicité et des droits de la personne, et les preuves de marginalisation. Un bref historique de la formation médicale postdoctorale et du processus de sélection des résidents est présenté, ainsi qu'une brève analyse juridique du pouvoir décisionnel en matière d'admissibilité au CaRMS. Les pratiques actuelles du CaRMS sont situées dans le contexte de la législation provinciale sur l'équité, et les rationalisations et raisons d'être du système CaRMS actuel sont explorées. L'article comprend un examen des indicateurs objectifs de la compétence des DIM et de la législation relative à la reconnaissance des titres de compétence internationaux et à la mobilité de la main-d'œuvre. Ces problématiques sont replacées dans le contexte des politiques et des pratiques exemplaires en vigueur en matière d'immigration et d'éducation. Une mise en perspective internationale est proposée par le biais d'une comparaison avec le National Residency Matching Program des États-Unis. Des suggestions pour modifier le système CaRMS actuel sont présentées, afin de rendre le processus plus conforme à la législation et aux valeurs canadiennes d'aujourd'hui comme celle exprimée par le slogan « Un Canadien est un Canadien. ¼.

Investigation of Brucella melitensis in Sable Antelope (Hippotragus niger) in South Africa.

In this study, Brucella melitensis infection in sable antelope (Hippotragus niger) was investigated on two wildlife ranches in South Africa over a 12-year period in order to determine the origin of the outbreaks and the role of livestock in maintaining the disease. Retrospective data were obtained from farm records and interviews as well as samples tested from different disease scenarios and clinical settings. On one ranch, 10 of 74 sable tested seropositive for B. melitensis in 2004 but were certified clear of infection after no further brucellosis cases were detected following repeated serological tests and culling over a five-year period. Recrudescence occurred in 2013 (7 of 187 brucellosis positives) and in 2014 (one positive), with persistent, latent infection being the most reasonable explanation. In a second case study, linked to the first one through a common vendor, 15 of 80 sable tested positive in 2016, some five years after the acquisition of the animals from a putative source. Brucella melitensis biovar 1 and/or 3 were isolated from each outbreak on both ranches. Both outbreaks resulted in substantial losses for the owners, arising from testing and culling and significant resource expenditure by the state. The study identified the diagnostic challenges for identifying and resolving disease outbreaks in wildlife, the persistence of B. melitensis in sable, the risks associated with animal movements, and the need for a wildlife-sensitive disease control scheme. Although the actual source of infection could not be identified, the investigation points away from local livestock as a source of ongoing infection while the persistent infection is consistent with the disease circulating within small, ranched populations and being spread through the keeping and trading of high-value animals. The implications of the study findings to disease control in wildlife are discussed.

Epidemiologic and virologic assessment of the 2009 influenza A (H1N1) pandemic on selected temperate countries in the Southern Hemisphere: Argentina, Australia, Chile, New Zealand and South Africa.

UNLABELLED: INTRODUCTION AND SETTING: Our analysis compares the most comprehensive epidemiologic and virologic surveillance data compiled to date for laboratory-confirmed H1N1pdm patients between 1 April 2009 - 31 January 2010 from five temperate countries in the Southern Hemisphere-Argentina, Australia, Chile, New Zealand, and South Africa. OBJECTIVE: We evaluate transmission dynamics, indicators of severity, and describe the co-circulation of H1N1pdm with seasonal influenza viruses. RESULTS: In the five countries, H1N1pdm became the predominant influenza strain within weeks of initial detection. South Africa was unique, first experiencing a seasonal H3N2 wave, followed by a distinct H1N1pdm wave. Compared with the 2007 and 2008 influenza seasons, the peak of influenza-like illness (ILI) activity in four of the five countries was 3-6 times higher with peak ILI consultation rates ranging from 35/1,000 consultations/week in Australia to 275/100,000 population/week in New Zealand. Transmission was similar in all countries with the reproductive rate ranging from 1.2-1.6. The median age of patients in all countries increased with increasing severity of disease, 4-14% of all hospitalized cases required critical care, and 26-68% of fatal patients were reported to have ≥1 chronic medical condition. Compared with seasonal influenza, there was a notable downward shift in age among severe cases with the highest population-based hospitalization rates among children <5 years old. National population-based mortality rates ranged from 0.8-1.5/100,000. CONCLUSIONS: The difficulty experienced in tracking the progress of the pandemic globally, estimating its severity early on, and comparing information across countries argues for improved routine surveillance and standardization of investigative approaches and data reporting methods.

A lethal case of pneumatosis intestinalis complicated by small bowel volvulus.

Pneumatosis intestinalis (PI) is a condition characterised by gas-filled cystic malformations on the intestinal wall. It is often secondary to an underlying disease process. We describe the case of a 76-year-old gentleman who presented with intermittent abdominal pain, altered bowel habits and weight loss. Barium enema was unremarkable, apart from sigmoid diverticulosis. CT scan found evidence of pneumatosis on small bowel walls with benign pneumoperitoneum. As there was no sign of intra-abdominal crisis, he was initially treated conservatively. Unfortunately, he required re-admission 6 weeks later with symptoms of bowel obstruction and clinical signs of perotinitis. At laparotomy, he was found to have extensive small bowel infarction due to volvulus from 'twisting' around the axis of superior mesenteric vessels. Evidently, this occurred secondary to a congenitally long small bowel mesentery that predisposed him to volvulus. Extensive small bowel resection was performed. The postoperative course was complicated by persistent hypotension, which proved fatal. This case report draws attention to the rare association between PI and small bowel volvulus predisposed by a congenitally long mesentery, which can present initially with a benign picture (intermittent, reversible volvulus), but subsequently be complicated by lethal bowel infarction (irreversible volvulus). This case raises several issues about the management of this rare condition. Clinicians must realise that PI, though often benign, can present with lethal complications, and early recognition of such complications can be life-saving.

A case of gallstone-induced small bowel necrosis masquerading as clinical appendicitis.

Cholecysto-duodenal fistula and gallstone ileus are well-recognised complications of gallstone disease. However, small bowel necrosis is a rare complication of gallstone disease. We describe a case of gallstone-induced ileal necrosis presenting with symptoms and signs resembling acute appendicitis. A 79-year-old woman presented to the surgical team with central abdominal pain which subsequently shifted to the right iliac fossa. Clinically, the patient had localised perotinism in the right iliac fossa with high inflammatory markers. Abdominal radiography showed no diagnostic features. Initial clinical impression was that of acute appendicitis. Given that this diagnosis was unlikely in a patient of this age, an abdominal CT scan was performed. The CT scan showed evidence of a large gallstone causing small bowel obstruction in the presence of a cholecysto-duodenal fistula. At surgery, she was found to have an area of necrosis with a pin-point perforation at the site of impaction of the gallstone in the proximal ileum. This occurred secondarily to pressure necrosis from the gallstone impacting at a site where the small bowel diameter narrows in transition from jejunum to ileum. A limited small bowel resection was performed with an uncomplicated postoperative course. This case report draws attention to a rare complication of gallstone disease which presents with a clinical picture similar to acute appendicitis. Preoperative investigation for an elderly patient who presents with an acute abdomen should include an abdominal CT scan to diagnose any rare disease processes which otherwise may not be suspected.