Minority report: how the UK's treatment of foreign and ethnic minority doctors needs to change

The challenges faced by early career international medical graduates in general practice and opportunities for supporting them: a rapid review

BACKGROUND

British general practice is facing a workforce crisis against a backdrop of an ageing population experiencing increasingly complex health challenges. The NHS must increase the supply of GPs, including international medical graduate (IMG) GPs, by increasing recruitment and retention. IMG GPs face distinct challenges during training and their early careers. Understanding these challenges, as well as the help and support offered to early career IMG GPs, is crucial to building and sustaining the general practice workforce.

AIM

To understand the challenges facing early career IMG GPs and the help and support they can access.

DESIGN & SETTING

Rapid review of studies and grey literature on UK-based IMG GPs.

METHOD

Six databases were searched. Four websites were searched to find grey literature. Titles and abstracts were screened according to inclusion and exclusion criteria, followed by the full study where applicable. The included studies were analysed using a thematic synthesis approach to identify the challenges faced by early career IMG GPs, as well as the help and support available.

RESULTS

The database search yielded 234 studies, with 38 additional studies identified via other methods. Twenty-one studies were included in the synthesis. Seven challenges were identified, as well as a range of help and support available. Early career IMG GPs face a range of psychological, social, and practical challenges, which may not be adequately addressed by the help and support currently offered by the NHS.

CONCLUSION

Further research is required to understand the extent to which early career IMG GPs access the help and support offered, and if it adequately addresses the unique challenges they face.

A Cohort Study of the Diversity in Animated Films From 1937 to 2021: In a World Less Enchanted Can We Be More Encanto?

Background Exposure to gender stereotypes in the media can develop and reinforce these attitudes in children. Individuals who are overweight, have health conditions, or are from a minority ethnic group (IMEG) are both underrepresented and poorly portrayed in the media. Role models can raise the aspirations of young children both professionally and in taking ownership of their health. We aimed to assess how the portrayal and diversity of characters in Disney, Pixar, and Dreamworks animated films have changed over time. Method A cohort study of all main characters in Disney, Pixar, and Dreamworks feature-length, theatrical, animated films from 1937 to 2021 was conducted. The portrayal of characters (R-score divided into negative, neutral, and positive -1, 0, and 1, respectively) was scored. The proportion of individuals with certain protected characteristics (sex, increased body mass index, physical or mental health conditions, being from an IMEG or part of the lesbian, gay, bisexual, transexual, and queer community) was also recorded. Results In total, 116 films and 1,275 characters were included. From the 1930s to 2020s, the proportion of women in films increased (16.7% to 47.3%, p=0.008) and their representation was more positive (mean R-score = -0.10 (SD:0.692) versus 0.49 (SD:0.837), p<0.001, respectively). The portrayal of overweight individuals has improved to a neutral position (mean R-score: -0.67 to 0.0). Both physical and mental illnesses are better portrayed (mean R-score: -0.18 to 0.34, p=0.004 and 0.5 to 1.0, p= 0.019, respectively). IMEGs introduced in 1953 now play more than just negative roles (mean R-score = -1 to 0.76, p=0.008). There is only one explicitly stated homosexual character. The most diverse film is Encanto. Conclusion This is the first study to comprehensively assess the diversity of animated film characters. We have identified an improvement in diversity and the way diverse individuals are portrayed which we hope continues.

(Re)producing "Whiteness" in Health Care: A Spatial Analysis of the Critical Literature on the Integration of Internationally Educated Health Care Professionals in the Canadian Workforce

PURPOSE

There is a gap in the literature to understand how professionalizing systems intersect with socioeconomic and political realities such as globalization to (re)produce social inequities between those trained locally and those trained abroad. In this critical review, the question of how systemic racism is reproduced in health care is addressed.

METHOD

Electronic databases and nontraditional avenues for searching literature such as reference chaining and discussions with experts were employed to build an archive of texts related to integration of internationally educated health care professionals (IEHPs) into the workforce. Data related to workplace racialization were sought out, particularly those that used antiracist and postcolonial approaches. Rather than an exhaustive summary of the data, a critical review contributes to theory building and a spatial analysis was overlayed on the critical literature of IEHP integration to conceptualize the material effects of the convergence of globalization and professional systems.

RESULTS

The critical review suggests that professions maintain their value and social status through discourses of "Canadianness" that maintain the homogeneity of professional spaces through social closure mechanisms of credential nonrecognition and resocialization. Power relations are maintained through mechanisms of workplace racialization/spatialization and surveillance which operate through discourses of "foreign-trainedness."

CONCLUSIONS

Movement of professionals supports a professional system that on the surface values diversity while maintaining its social status and power through the (re)production of the discourse of "Whiteness." The analysis shows how in the process domestic graduates are emplaced as the "rightful" citizens of professional paces while IEHPs are marginalized in the workforce.

Moving beyond orientations: a multiple case study of the residency experiences of Canadian-born and immigrant international medical graduates

Many international medical graduates (IMGs) enter North American residency programs every year. The Canadian IMG physician pool increasingly includes Canadian-born IMGs (C-IMGs) along with Immigrant-IMGs (I-IMGs). Similar trends exist in the United States. Our objective was to understand the similarities and differences in the challenges faced by both I-IMGs and C-IMGs during residency to identify actionable recommendations to support them during this critical time. We performed a multiple case study of IMGs' experiences at a large Canadian university. Within our two descriptive cases (I-IMGs, C-IMGs) we iteratively conducted twenty-two semi-structured interviews; we thematically analyzed our data within, between, and across both cases to understand challenges to IMGs' integration and opportunities for curricular innovations to facilitate their adaptation process. Research team members with different perspectives contributed reflexively to the thematic analysis. Participants identified key differences between medical culture and knowledge expected in Canada and the health systems and curricula in which they originally trained. I-IMG and C-IMG participants perceived two major challenges: discrimination because of negative labelling as IMGs and difficulties navigating their initial residency months. C-IMGs described a third challenge: frustration around the focus on the needs of I-IMGs. Participants from both groups identified two major opportunities: their desire to help other IMGs and a need for mentorship. I-IMGs and C-IMGs face diverse challenges during their training, including disorientation and discrimination. We identified specific objectives to inform the design of curriculum and support services that residency programs can offer trainees as well as important targets for resident education and faculty development.

Rationales for expanding minority physician representation in the workforce: a scoping review

OBJECTIVES

The purpose of this study was to conduct a scoping review of the literature and to categorically map a 15-year trajectory of US undergraduate medical education rationales for and approaches to expanding under-represented minority (URM) physician representation in the medical workforce. Further aims were to comparatively examine related justifications and to consider international implications.

METHODS

From 1 June to 31 July 2015, the authors searched the Cochrane Library, ERIC, PsycINFO, PubMed, Scopus, Web of Science and Google Scholar for articles published between 2000 and 2015 reporting rationales for and approaches to increasing the numbers of members of URMs in undergraduate medical school.

RESULTS

A total of 137 articles were included in the scoping review. Of these, 114 (83%) mentioned workforce diversity and 73 (53%) mentioned concordance. The patient-physician relationship (n = 52, 38%) and service commitment (n = 52, 38%) were the most commonly cited rationales. The most frequently mentioned approaches to increasing minority representation were pipeline programmes (n = 59, 43%), changes in affirmative action laws (n = 32, 23%) and changes in admission policies (n = 29, 21%).

CONCLUSIONS

This scoping review of the 2000-2015 literature on strategies for and approaches to expanding URM representation in medicine reveals a repetitive, amplifying message of URM physician service commitment to vulnerable populations in medically underserved communities. Such message repetition reinforces policies and practices that might limit the full scope of URM practice, research and leadership opportunities in medicine. Cross-nationally, service commitment and patient-physician concordance benefits admittedly respond to recognised societal need, yet there is an associated risk for instrumentally singling out members of URMs to fulfil that need. The proceedings of a 2001 US Institute of Medicine symposium warned against creating a deterministic expectation that URM physicians provide care to minority populations. Our findings suggest that the expanding emphasis on URM service commitment and patient-physician concordance benefits warrants ongoing scrutiny and, more broadly, represent a cautionary tale of unintended consequences for medical educators globally.

Predicting fitness to practise events in international medical graduates who registered as UK doctors via the Professional and Linguistic Assessments Board (PLAB) system: a national cohort study

BACKGROUND

International medical graduates working in the UK are more likely to be censured in relation to fitness to practise compared to home graduates. Performance on the General Medical Council's (GMC's) Professional and Linguistic Assessments Board (PLAB) tests and English fluency have previously been shown to predict later educational performance in this group of doctors. It is unknown whether the PLAB system is also a valid predictor of unprofessional behaviour and malpractice. The findings would have implications for regulatory policy.

METHODS

This was an observational study linking data relating to fitness to practise events (referral or censure), PLAB performance, demographic variables and English language competence, as evaluated via the International English Language Test System (IELTS). Data from 27,330 international medical graduates registered with the GMC were analysed, including 210 doctors who had been sanctioned in relation to at least one fitness to practise issue. The main outcome was risk of eventual censure (including a warning).

RESULTS

The significant univariable educational predictors of eventual censure (versus no censures or referrals) were lower PLAB part 1 (hazard ratio [HR], 0.99; 95% confidence interval, 0.98 to 1.00) and part 2 scores (HR, 0.94; 0.91 to 0.97) at first sitting, multiple attempts at both parts of the PLAB, lower IELTS reading (HR, 0.79; 0.65 to 0.94) and listening scores (HR, 0.76; 0.62 to 0.93) and higher IELTS speaking scores (HR, 1.28; 1.04 to 1.57). Multiple resits at either part of the PLAB and higher IELTS speaking score (HR, 1.49; 1.20 to 1.84) were also independent predictors of censure. We estimated that the proposed limit of four attempts at both parts of the PLAB would reduce the risk in this entire group by only approximately two censures per 5 years in this group of doctors.

CONCLUSIONS

Making the PLAB, or any replacement assessment, more stringent and raising the required standards of English reading and listening may result in fewer fitness to practice events in international medical graduates. However, the number of PLAB resits permitted would have to be further capped to meaningfully impact the risk of sanctions in this group of doctors.

Does a host country capture knowledge of migrant doctors and how might it? A study of UK doctors in New Zealand

OBJECTIVES

To investigate International Medical Graduate (IMG) perspectives on opportunities to share technical knowledge and professional experience with host country professionals and mechanisms for this.

METHODS

All IMGs from the UK registered with the New Zealand Medical Council who had arrived within the decade to 2014 were surveyed (n = 1357). The main outcome measures were respondent perceptions of host country receptivity to their potential knowledge contribution, and mechanisms through which knowledge might be shared.

RESULTS

The survey response rate was 47 % (n = 632). 82 % of respondents agreed colleagues had been receptive to their knowledge contribution; 67 % felt they had been encouraged to share professional knowledge gained abroad; 60 % agreed they had been encouraged to share knowledge of the UK or other health systems. Only 45 % believed there were clear mechanisms in place for knowledge sharing. Statistically significant differences by age and professional practice designation were found.

CONCLUSIONS

Knowledge transfer in the New Zealand context appeared to be relatively ad hoc. Options for improving knowledge transfer include formal organisational arrangements, use of knowledge brokers and building communities of practice in different areas.

What motivates doctors to leave the UK NHS for a "life in the sun" in New Zealand; and, once there, why don't they stay?

BACKGROUND

At 44%, New Zealand has the highest proportion of international medical graduates (IMGs) in its workforce amongst OECD member countries. Around half of New Zealand's IMGs come from the UK NHS, yet only around 50% stay longer than 1 year post-registration with significant costs to the New Zealand health care system. Why these doctors go to New Zealand and do not stay for long is an important question.

METHODS

UK-trained doctors who had gained registration with the Medical Council of New Zealand and currently practising in New Zealand were surveyed (n = 1357) on the motivation for their move to New Zealand, experiences once there and what was prompting any intentions to move away from New Zealand. Multivariate proportional odds models (POM) were used to quantify various associations.

RESULTS

The survey had a 47% response (n = 632). Quality of life considerations motivated 96% of respondents to move to New Zealand, although 65% indicated they were pushed by a desire to leave the NHS. POM analyses revealed older respondents were significantly less likely than younger respondents to be motivated by quality of life considerations. Younger doctors were significantly more likely to be seeking to leave the NHS. Seventy-six per cent of respondents signalling an intention to leave New Zealand indicated that the desire to return to the UK was the primary reason for this.

CONCLUSION

There is a long history of medical migration from the UK to New Zealand. However, the 65% of respondents in this study seeking to leave the NHS was much higher than found elsewhere, perhaps reflecting increasing workplace and funding pressures in recent years. Of concern to policy makers were the higher odds of seeking to leave the NHS motivating younger doctors. Various changes "down under", in New Zealand as well as Australia, mean their IMG markets may well be tightening up.