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

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.