RESUMEN
OBJECTIVES: International medical graduates (IMGs) perform less well in national postgraduate licensing examinations compared with UK graduates, even in computer-marked multiple-choice licensing examinations. We aimed to investigate thought processes of candidates answering multiple- choice questions, considering possible reasons for differential attainment between IMGs and UK graduates. DESIGN: We employed a semistructured qualitative design using cognitive interviews. Systematic grounded theory was used to analyse data from 'think aloud' interviews of general practitioner specialty trainees (GPSTs) while answering up to 15 live questions from the UK Membership of the Royal College of General Practitioners Applied Knowledge Test (AKT). SETTING: East Midlands, UK. PARTICIPANTS: 21 GPSTs including 13IMGs and 8 UK-trained doctors. OUTCOMES: Perceptions of participants on how they answered AKT questions together with strategies used or difficulties experienced. RESULTS: We interviewed 21 GPSTs (8 female, 13 male, 13 IMGs, 14 from black and minority ethnic groups, age 24-64 years) in years 1-3 of training between January and April 2017. Four themes were identified. 'Theoretical versus real-life clinical experience': participants reported difficulties recalling information and responding to questions from theoretical learning compared with clinical exposure; rote learning helped some IMGs recall rare disease patterns. Recency, frequency, opportunity and relevance: participants reported greater difficulty answering questions not recently studied, less frequently encountered or perceived as less relevant. Competence versus insight: some participants were over optimistic about their performance despite answering incorrectly. Cultural barriers: for IMGs included differences in undergraduate experience, lack of familiarity with UK guidelines and language barriers which overlapped with the other themes. CONCLUSIONS: The difficulties we identified in candidates when answering AKT questions may be addressed through training. IMGs face additional difficulties which impede examination success due to differences in educational experience, content familiarity and language, which are also potentially amenable to additional training support.