Keywords
international medical graduates - enablers - challenges - National Health Service
- surgical trainees
Introduction
International medical graduates (IMGs) can provide excellent quality care and contribute
to patients' experience, enhancing the health care sector's performance and reputation.[1] Their efficient integration into the National Health Service (NHS) is crucial for
providing effective clinical services.[2] However, despite the high demand for health care workers in the NHS, IMGs' previous
experience and clinical skills may need to be adequately utilized. They face many
problems and difficulties, such as isolation from family, inadequate employment opportunities,
language and cultural barriers, and lack of support from supervisors,[3] which can lead to lower motivation, high turnover, and lower retention. This further
impairs their ability to adapt and use their professional skills/training, and, in
turn, potentially affects patient safety—a vicious cycle.[2] In the United Kingdom, IMGs have limited access to comprehensive inductions through
the local hospital and General Medical Council, making adapting to the NHS difficult.[4]
[5] Furthermore, the lack of organized training and high service demands often result
in suboptimal supervision and limited feedback on clinical performance. It is also
well known that some IMGs find feedback to be unhelpful and are not open to feedback
or improvement, are not able to adapt to the local medical practices and guidelines,
are afraid to say “no,” and are afraid to ask questions or seek help when required.[6]
Successful integration into the health care system necessitates cultural awareness,
professional and social support networks, personal attributes, social integration,
communication, and English language skills. However, barriers to integration include
a lack of understanding of the structure and values of the NHS, medicolegal and ethical
issues, heavy administrative workload, deficient orientation, varying learning strategies
in the United Kingdom, cultural differences, and criticism from colleagues. As IMGs
constitute 20 to 30% of the United Kingdom's medical workforce and their numbers are
expected to increase, this issue is crucial to the country's medical field. While
there is limited educational literature on the barriers they face while studying in
the United Kingdom, this qualitative research focuses on the enablers and barriers
to IMGs adapting to the NHS. The main aim of this research is to identify enablers,
facilitators, barriers, and potential solutions that contribute to optimizing the
adaptation of IMGs in a defined cohort registered to the Master of Surgery (MCh) program
in general surgery affiliated with Edge Hill University in the United Kingdom. Interviews
were conducted with the first-year MCh trainees working in the NHS for a few months
to uncover any issues registered to the 2022 cohort affiliated with Edge Hill University.
Although many of the findings are generalizable to any IMG, this service improvement
project is specifically focused on the MCh general surgery trainees registered at
Edge Hill University.
Methods
This was a qualitative study and the methods used included interpretivism philosophy,
descriptive design, inductive approach, primary data collection, interview schedule,
qualitative data analysis, and sampling techniques.
Context
Edge Hill University has a well-established master's program in surgery specifically
for IMGs. These trainees have undergone the selection process in India and have experience
with General Medical Council (GMC) registration and visa issues. The MCh program is
an academic program where the selected trainees are registered with Edge Hill University
for a 2-year master's program. In parallel, they do their clinical placement at one
of the hospitals in the Northwest England. In the first year, these trainees work
as international training fellows' year 1 (ITF 1) where they are involved more in
the perioperative care of the patients and gain some operating experience under supervision.
In the second year, following the successful completion of their performance review,
these trainees move to year 2, where they gain more operating experience under supervision,
which means more responsibility and accountability.[7] Around 70 trainees are enrolled in the surgery stream, with 13 trainees in the first
year of the master's in general surgery stream of the program.
Data Collection
Year 1 students were chosen to participate in the study as they have gone through
the interview, selection, visa, and NHS job processes, making it possible to assess
their relocation from their home country and start their NHS jobs. Students who did
not belong to either year 1 or were not in the surgery stream were excluded from the
study. To enhance response rates, the MCh administrative team sent a precontact introductory
letter ([Supplementary material 1], available in online version only) to the 15 students in cohort regarding this qualitative
research.[8] This was followed by participant invitations to MCh surgical trainees along with
a Participant Information Sheet ([Supplementary material 2], available in online version only), and written consent ([Supplementary material 3], available in online version only) was then obtained from those who wished to participate.
The focus group method was aligned with the study's constructivist philosophy, and
the lead author (C.R.S.) conducted three focus group discussions using Zoom, with
each group discussion lasting approximately 90 minutes. Zoom has the facility to auto-transcribe
the whole interview process, and this was supplemented with notes taken by the researcher
to document group dynamics, nonverbal interaction, emotions, silences, and linguistics.[9] To prevent adverse power dynamics, homogeneous participants were selected. Questions
were designed to facilitate discussion and were focused on the experiences and thoughts
of the participants. The author (C.R.S.) moderated the discussions and made it clear
that participation was voluntary. Two focus groups had two members each, and the third
group had three. The researcher attempted to conduct more focus groups, but due to
on-call duties and clinical and social commitments, it was not possible. During moderation,
opinion was sought on the IMGs' perceptions of the enablers and challenges, potential
solutions, and questions that might be asked of IMGs aligned with the research aims.
Similarly, the IMG focus group questions guided discussion around their experiences
relevant to the research questions.
Analysis
Data analysis employed the concept of “convergence of evidence” triangulating (cross-referencing)
data from different sources, thereby constructing themes from the many realities of
participants and, in so doing, establishing theory. A “ground up” thematic analysis
was undertaken inductively to generate themes from which theories could be developed,
enhanced by memo-writing (referring to notes made concurrently during data analysis)
and diagramming.[10] The analysis technique employed cycles of an iteration involving multiple appraisals
of the data to generate codes at each stage and to revise these codes as more data
were analyzed and the previous data reread. Data were included in the transcription
and analysis since they contained valuable information.[11]
The basic level of coding was descriptive, generating open codes manually. During
the iterative cycle, the data were reduced and linked under higher-level headings
(axial codes). Finally, selective codes were generated to indicate central categories.[11]
[12] The concepts generated from these categories informed the generation of themes.
The themes generated in the three preliminary focus group meetings were integrated
into a single dataset and combined to generate common themes.
The ethical framework of the study followed the guidelines of the British Educational
Research Association (2018) and was cross-referenced with additional texts[13]
[14] for comprehensive coverage. The project received approval from Edge Hill University
and the Clinical Lead for the MCh program, and it is registered as a service evaluation
at the Christie NHS Foundation Trust ([Supplementary material 4], available in online version only; QICA approval). Data were stored securely in
a password-protected Christie NHS Foundation Trust account. Paper documents and tapes
were stored in a locked cabinet accessible only by the researcher. On completion,
data will be held in line with the regulations at Edge Hill University.
Results
Three focus groups with a total of seven participants contributed to the data collection.
All trainees enrolled in this program had completed their basic medical and postgraduate
surgical training in their home country and their postgraduation was within 5 years
of enrolling in the master's program at Edge Hill University ([Table 1]). All selected trainees for this program had completed the English language assessment.
Table 1
Details of the country of training of international medical graduates
|
Country of training
|
Number
|
|
India
|
6
|
|
Iran
|
1
|
|
Total
|
7
|
Theme 1:
Enablers that facilitate adaptation to NHS of the “international medical graduates.”
Some enablers include the usefulness of communication courses, good support from hospital
staff and colleagues, university support, and administration support starting from
the entry into the United Kingdom and continuing throughout the process. IMG 1 said
that “Rachel from the administrative team provided excellent support following the
interview in getting registration and visa process.”
IMG 3 said that there was “regular contact from a designated person in the university, so during my applications for the university, there was regular phone contact from
the university administrative team. So, there was a contact person. Regular interaction
with administrative staff was helpful during the assessment and when applying to the
university.”
IMG 4 mentioned “Help with paperwork from the hospital, Helpful colleagues, Classes
on communication skills, support from nurses, induction classes, shadowing, the support
provided by the program, and help with paperwork from the hospital” as other major
helpful aspects.
Factors that facilitate integration include knowledge and improved practical knowledge,
the ability to solve problems and provide better solutions, and being able to handle
any situation and provide care to patients. One of the IMGs emphasized the importance
of being able to handle any situation and provide care to patients as the most important
factor in facilitating the integration of IMGs into the NHS.
Theme 2:
Challenges faced by IMGs in adapting to the NHS.
There are certain hindrances that the IMGs face in adapting to the NHS. For instance,
IMG 1 mention the following as one of the major barriers that have a greater influence
on the overall context: “Limited insight into what the role and life will be like
in the United Kingdom and as well as the Food.” According IMG1 1:
“The thing that was challenging was the diet. But we are used to Bangalore too, so
we are used to a lot of varieties and flavours. Suddenly we come to eat potatoes and
eggs along with some bland. I don't blame them, but that is fine. That probably is
not my cup of tea. So, there are personal challenges that will probably be enough
to face. And it's not just economical but there are probably some geographical things
we have to expect.”
IMG 3 mentioned “patients' accent and cultural differences in taking consent” as a
barrier for the IMGs in terms of adapting to the NHS. He stated:
“It was different. It was different from the medical college where I went. It was
different from the corporate hospital, and it is different here. This had a starting
difficulty; maybe I should have shadowed and registered for consent training. They
showed me how to consent and some of the points were different from India where as
you know we don't say openly or discuss with the patient the complications that don't
happen on a recurring basis.”
Some challenges that hinder IMGs from adapting to the NHS have been identified. These
hindrances include limited access to formal teaching, an extremely fast academic work,
limited insight into work and life in the United Kingdom, challenges with the local
English accent and cultural differences in communication, variations in practice,
lack of transparency, public awareness, limited social networks, and diet. Lack of
access to teaching was mentioned as a major challenge by one IMG. These challenges
have been identified through interviews and previous literature.
All the themes identified in the three focus group interviews were collated into one
dataset and used as codes to generate common themes identified, as detailed in [Tables 2] and [3].[10]
Table 2
Enablers
|
Enablers
|
|
• Administrative support (from the start to entering the UK, accommodation, pastoral
support)
|
|
• Hospital staff support is good
|
|
• University support
|
|
• Communication course is useful
|
|
• Mentorship program with pastoral support
|
Table 3
Challenges
|
Challenges
|
|
• Access to formal teaching available to local trainees
|
|
• Academic work pace was fast
|
|
• Limited insight into the work and the life in the UK
|
|
• English accent
|
|
• Communication with cultural differences including consent
|
|
• Variations in practice
|
|
• Openness and transparency are key
|
|
• Public has more awareness and more time is needed to explain in depth
|
|
• At least in India, we have a family who will take care of them (social network is
limited)
|
|
• Diet (information on food availabilities? Vegetarian)
|
Theme 3:
Factors preventing and facilitating the integration of surgical IMGs into the NHS.
Several factors have a huge influence on the integration of surgical IMGs into the
NHS. Trainee 1 suggested that lack of expertise as one of the major issues. Lack of
experience and expertise in the surgical process can prevent the integration of surgical
IMGs into the NHS. Another factor, as per an IMG, that can hinder the integration
of surgical IMGs is the language barrier. While many surgical IMGs have a high level
of English proficiency, differences in terminology and communication styles can still
pose significant challenges. This can lead to misunderstandings, difficulties in building
relationships with colleagues and patients, and barriers to effective teamwork.[15]
Several factors can facilitate the integration of surgical IMGs into the NHS. According
to IMG 1: “One of the most significant is the condition of appropriate support and
mentorship programs.” These programs can help IMGs navigate the complexities of the
NHS, guide career development, and offer opportunities for professional networking.
Additionally, IMG 3 believed that “improving cultural awareness and diversity training
for all staff can help to create a more inclusive and welcoming workplace culture.”
During an interview, various enablers that have influenced the adaptation of IMGs
in the NHS were identified. Operational managers of MCh programme were always contactable
and responded to e-mails and telephone calls swiftly. Regular contact from a designated
person in the university, support from the university and administration, assistance
with obtaining a visa, help with paperwork from the hospital, helpful colleagues,
classes on communication skills, nurses, induction classes, and shadowing are some
of the major enablers mentioned by the speakers. IMG 4 specifically mentioned that
assistance with obtaining a visa was a major enabler for him and that the program
also guided him through the examination process. Communication classes were also identified
as a major enabler for IMGs.
Theme 4:
Recommendations for better adaptation of IMGs to the NHS.
IMGs play a crucial role in the United Kingdom's NHS workforce, but they can face
challenges in adapting to the new environment. To support better adaptation for IMGs,
it is recommended to provide them with information about the NHS culture, language,
and communication skills. Additionally, mentors can offer guidance and support during
their transition. Cultural competence training for NHS staff can promote understanding
and empathy toward IMGs. Language proficiency standards should be met and support
should be provided for improving language skills. Opportunities for career progression
and continuing professional development should also be offered. By implementing these
recommendations, the NHS can better support IMGs and contribute to a diverse and inclusive
workforce. It is important to ensure that IMGs feel valued and supported in the workplace,
which can ultimately lead to better patient care and outcomes.
Discussion
Apart from one trainee, the rest were from India. This non-Indian trainee although
concurred with the discussion with the Indian colleagues and brought in some unique
issues such as challenges in obtaining a visa that was unique due to the political
situation in the country. This emphasized the constant need to review the study to
ensure updated intelligence is received from the delegates to make the program robust.
The data highlight the facilitating factors and challenges for medical graduates in
surgery specifically those registered to the MCh program.
The interviewees emphasized the importance of effective communication systems among
hospital staff and stakeholders, which allows international students to maintain their
medical practices. The data collected from the interviews revealed that support from
university and hospital staff is essential for enabling international students to
practice medicine within NHS hospitals. This aligns with studies that found communication
and support from staff and peers to be crucial for new employees and streamlined service
management.[6]
[15] Similarly, other studies emphasized the importance of proper communication methods
in enabling international students and employees from different countries to integrate
into the workplace environment. The interviewees also highlighted the significance
of university support in facilitating international students' integration into NHS
hospitals. Thus, external factors, such as university support, are crucial in enabling
international students to work in NHS hospitals in the United Kingdom.[6]
[15]
Interviews also revealed that proper processing of the application process for IMGs
and effective communication are essential for engaging with staff and enabling international
medical students to start their careers in NHS hospitals. The interview data emphasized
the importance of daily communication and proper communication with managers and senior
employees in managing the beginning of medical practices in the United Kingdom in
NHS hospitals.[15] This aligns with findings from the literature, suggesting that effective communication
with information about the processes is crucial for enabling international medical
students to practice in NHS hospitals.[6]
[15]
Understanding the challenges medical practitioners face is vital, and the interviews
conducted in the study shed light on the hindrances they encounter. According to the
interviewees, differences in ideas regarding public health and local practices pose
a significant obstacle. Additionally, various factors have impeded students' ability
to maintain their medical practices in NHS hospitals, such as differences in colloquial
English accents and discourse. The United Kingdom's educational system teaches a conception
of public health that differs from most of the students' home country, India. Moreover,
international students lack access to public health education. The Indian society's
approach to care and support services, which is largely family-based, contrasts with
that of the United Kingdom, where professionals provide care in care homes. Communication
issues and lack of awareness regarding public health services also affect the practices
of IMGs in NHS hospitals. Proper documentation management and data sharing are crucial
for United Kingdom medical and public health management. Insufficient knowledge of
legal policies and documentation management has hindered students' ability to practice
medicine in the United Kingdom. Existing literature highlights the enablers and hindrances
for new medical practitioners, such as communication gaps within hierarchies and lack
of knowledge about the lifestyles and discourses.[15]
Lack of practical experience and reflective practices among IMGs has been identified
as a major issue in medical practice, according to existing literature.[16] The combination of theoretical and practical knowledge is necessary for enhancing
medical practice. Lack of practical knowledge in surgery and after-surgery care in
the United Kingdom has hindered career opportunities for IMGs. Insufficient reflective
practice has also impacted problem-solving and critical thinking skills, which are
crucial for effective situation management.
Interview data suggest that reflective education practices, proper practical teaching
approaches, and knowledge sharing regarding skills and public health could help mitigate
these issues. Triangulating objective structured clinical examination (OSCE) and skill-based
teaching approaches, utilizing virtual class management, and advanced technology for
communication could also be effective solutions. Support classes on cross-cultural
communication and teamwork management could also improve knowledge management. Cultural
awareness and understanding of teamwork can be essential enablers for IMGs' success
in the NHS in the United Kingdom.
After evaluating the programs, some issues that can be addressed with simple practices
have been identified. Overall, the surgery programs are performing well, but there
is room for improvement in certain areas. For example, trainers can provide clinical
videos to demonstrate the operation of the clinical setting and offer multiple methods
of communication, such as webinars, brochures, leaflets, and podcasts. These practices
will reduce the deficit of issues related to awareness and lack of education and improve
communication. Focusing on face-to-face “skill-based teaching” is also recommended
for better overall operations and management since it is more effective than virtual
teaching. Additionally, virtual classes can be added for “knowledge-based teaching”
to enhance teaching styles and improve knowledge among learners. Triangulating for
OSCE is another important suggestion that can be introduced to aid in improving knowledge
among students or candidates and help them with membership and fellowship examinations.
There are limitations of the study that have been recognized both in the data collection
method and in the analysis. The study was conducted with seven MCh students registered
at Edge Hill University in 2022. This is a small number; however, in the third interview,
no additional themes were found, which may suggest saturation was reached. The raw
data that have been provided by the interviewees are generally formulated from their
own experience, which although unique can sometimes deflect the major objective of
the research. This research was carried out in a selected group of trainees registered
for the MCh program. To validate this research, this process should be repeated in
other surgical specialties and within the future surgical cohort in the coming years.
Conclusion
Effective communication from universities and hospitals, proper communication methods,
and mentorship from senior health care professionals are crucial for facilitating
international medical practices in the United Kingdom. Lack of formal teaching on
the United Kingdom medical practices and differences in knowledge regarding public
health between their native cultures and the United Kingdom pose significant barriers
for IMGs. Proper induction methods with mentorship for medical practices could be
a crucial solution for enabling international medical students to ensure improved
integration into their professional practices in the United Kingdom NHS.
