In Reply to Hyder

We thank our colleague, Sadia Hyder, for commenting on our article published in a previous issue of the journal.1 We recognize her viewpoint that our discussion did not exhaust all the possible explanations for the increased rate of discipline amongst international medical graduates (IMGs) compared with North American medical graduates. Instead, our article serves as a primer on the subject—we hope that it will lead to more research endeavors in this field of patient safety. We continue to caution all readers against assuming that our proposed hypotheses are causative. However, we would challenge the hypothesis that transition periods are an important factor in disciplinary issues among IMGs. Interestingly, we found that most physicians in our cohort were disciplined an average of 32.8 years after graduating medical school.1 In other words, these physicians were disciplined at later stages in their careers. Although definitive data are unknown, we believe that a small proportion of IMGs start to practice medicine after 30 years of graduation. In this manner, the majority of the disciplined IMGs in our cohort had more than sufficient time in which to acclimatize to Canadian laws, values, and social norms prior to their disciplinary action. While it is certainly true that a heavy workload leading to physical and cognitive exhaustion may contribute to an increased risk for discipline, we are not convinced that this is more of an issue for individuals who trained outside of Canada but, rather, one that is faced by all physicians from all types of backgrounds. Nonetheless, we agree that mentorship, teaching, and a multitude of other guidance opportunities should be available to all physicians throughout their careers to potentially mitigate the occurrence of certain types of discipline. Still, there are no data to support that these types of programs have any effect on preventing disciplinary action. The interpretation of our data is cautious because the data objectively point to a simple association: Physicians who completed medical education outside of Canada had increased rates of discipline compared with domestically trained physicians. As mentioned above, our results provide a starting point for a discussion of why this phenomenon is observed. Preventing physician discipline is of utmost importance to improve patient safety; all physicians must take ownership and focus more attention upon this topic. We welcome other colleagues, including Dr. Hyder, to conduct further research into the complexities on why our findings have occurred. Asim Alam, MDStaff anesthesiologist and transfusion medicine specialist, Department of Anesthesia, Sunnybrook Health Sciences Centre, and Department of Anesthesia, University of Toronto, Toronto, Ontario; contact at Sunnybrook Health Sciences Centre, Department of Anesthesia, 2075 Bayview Ave., Rm M3-200, Toronto, Ontario, M5G 1X5, Canada. Jessica J. Lui, MD, MScGeneral medical internist, Division of General Internal Medicine, University Health Network and Department of Medicine, University of Toronto, Ontario, Canada. Chaim M. Bell, MD, PhDDeputy physician-in-chief, Division of General Internal Medicine, Mt. Sinai Hospital and Department of Medicine, University of Toronto, Toronto, Ontario, Canada.

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