The Challenge of Coming From Elsewhere

In the last few years, many studies have addressed the topic of problems suffered by doctors working in the UK’s National Health Service (NHS). Most of them discuss similar issues – symptoms of burnout, mild to moderate depression, and anxiety. Although these are often referred to as “common mental health problems,” I view them as common integration problems.  Participants report struggling to sleep, losing interest in their jobs, and problems with colleagues and patients – some so severe that they are reported the General Medical Council (GMC), which has seen a leap in the number of doctors reported for disciplinary action.

Looking at the multicultural composition of doctors on the GMC register, I find myself wondering if migration has played a role in the development ofintegration problems. I myself moved from another country to work in the UK and know firsthand the challenges such a significant life change presents. Moreover, because my role as consultant histopathologist means I am responsible for education and training, I have become increasingly aware of the significance of different cultural backgrounds and how they can affect learning at every stage. In particular, the question that has gradually come to mind is whether the discomfort some doctors experience could be related to the fact that medicine in the UK is very much “multicultural” – there are many doctors from other countries, and no two doctors will have had the same formative experiences.

This phenomenon is so common now that doctors who obtained their primary degrees and qualifications outside the UK have been given a specific label: International Medical Graduates (IMGs). Although the study of medicine can be very similar from one country to the next, the culture often varies from country to country. “Culture” can be defined as a set of norms, values, and beliefs that form the basis of behavior and interaction between human beings – and that includes doctor-patient relationships, doctor-doctor relationships, and interactions with other staff in the healthcare system.

Within the public perception of IMGs – perhaps assisted by the role of the media in shaping public opinion about migrations, doctors, patients, and diseases – is the suggestion that there is something intrinsically different about these doctors. But is this difference seen as a positive or a negative? Regrettably, IMGs experience the latter far more frequently. For example, data from IMGs attending the NHS Practitioner Health Program show that they are more likely than non-IMGs to be involved in regulatory or disciplinary processes, usually following a performance issue at work (1). The most common referral cases are problems with patients, colleagues, or staff mostly due to unwritten behavioral rules, cultural and social norms – essentially, problems with integration into the system. For example, the recent high profile case of Hadiza Bawa-Garba (2)  has shown that some groups of doctors feel at particularly at risk, leading to a specific recommendation by the GMC’s independent review. The recommendation states, “The GMC should work with healthcare service providers, national bodies, and representatives of overseas doctors to develop a suite of support for doctors new to UK practice. This should include information about cultural and social issues, the structure of the NHS, contracts, and organization of training, induction, appraisal, and revalidation, professional development plans, and mentoring (3).” 

Previously, to address this increasing problem, the GMC and many other healthcare organizations collaborated on a series of assistive measures, which aim to support IMGs with their integration into the NHS (4,5,6,7).

Despite these measures, I – an IMG myself – did not feel that the issues at the heart of the problem had been fully addressed. As a result, I decided to gather data that might illustrate the magnitude of the problem – so I performed a systematic review to investigate the association between migration and integration into the NHS. The results were both surprising and informative! I discovered:

1. IMGs are a significant proportion of the medical workforce in western countries such as the UK, the US, Canada, Germany, and Malta. However, despite the significant contribution of IMGs to patient care in these systems, adapting to an unfamiliar healthcare system in a new country has become increasingly difficult as the number of new IMGs grows.
2. Most studies have focused on three main causes of difficulty for IMGS: the role of language/communication barriers, working in an unfamiliar world, and lack of familiarity with the legal and professional framework.
3. Some countries have concentrated their efforts on identifying resources to support IMGs, rather than exploring the underlying causes of their difficulties; for example, migration to a new country.
4. Other countries, the UK, for example, have focused on medico-legal aspects – including concerns about medical practice and patients’ ill-founded fears about the safety risks IMGs may pose.
5. There has been little exploration of the possibility of creating awareness of the impact of migration on IMGs’ wellbeing. On the contrary, by focusing on mental health problems, studies may give the false impression that most doctors migrating from other countries bring such problems with them. As a consequence, the general population may doubt IMGs’ ability to provide safe and compassionate care. How can you care for someone else if you can’t care for yourself?

I am sure the last sentence will resonate with Hippocrates’ Corpus, which clearly states that, if a doctor is well-presented and well-dressed, patients will not have reservations about their ability to provide care. This last point, of course, is tongue-in-cheek – but it betrays a stark reality: that IMGs, despite being fundamental to many healthcare systems, face significant challenges integrating into them. It’s my hope that, by spreading awareness, we can begin to make changes to the way we assist new doctors in integrating into our countries and our lives.