Weeks after beginning its winding journey, a redirected letter finally finds its destination. In our eagerness to open it, we almost tear in half the neatly folded crisp white sheet that lists a series of results: angina, pass; asthma, pass; preeclampsia, pass; bulimia, fail, could not elicit history of vomiting; croup, pass. The list continues to a dispassionate conclusion that the candidate has demonstrated adequate knowledge at the examinations of the Australian Medical Council (AMC) to secure a passing grade. The accompanying card graciously thanks us for our tutoring 1 year ago. We stare wordlessly at the sheet, our joy obliterating its sterility.

So far, he has fled state persecution, worked 10 years in a factory, and supported a family of four on a minimum wage. The iatrogenic death of his father served as a powerful impetus to return to his calling in life, medicine. Forty years old, he has juggled swimming and soccer lessons, school homework and, lately, running a small business to steal time to prepare for his own examinations. “I promised myself at my father’s bedside that I would go back to medicine. Every day in the factory, I used to dream about becoming a doctor again, but we needed that job to survive.”

Now he will forever be known as an “AMC”. As we exuberantly write him a congratulatory note, a vision of his journey ahead involuntarily crosses our mind.

As he begins his quest for a job, he will quickly learn that, although all foreign graduates seeking to enter the Australian medical system must take the AMC exam, the term “AMC doctor” automatically carries the connotation of inferiority. Irish, American and German doctors will be identified by country, while he and his peers from the developing world will be separated by an invisible, but distressingly tangible, line. Deeming himself unsuitable for the elite hospitals, he will apply instead to those considered more “foreigner-friendly”, their reputation earned not necessarily for their greater tolerance of foreign graduates, but because of their inability to attract the more aspiring. These hospitals too will first select local graduates before yielding the leftover spots to the AMCs. At the scant interviews he secures, he will be summarily discarded at some on account of his thick (yet understandable) accent and his slow (yet considered) speech. At others, he is unlikely to receive ticks in the boxes that say “team player”, “enthusiastic” and “makes good eye contact”, because he is unfamiliar with the buzzwords and gestures (although not the inherent concepts) that interviewers seek.

His first job is almost certain to be in a hospital staffed largely, if not almost exclusively, by foreign doctors. Collegial support will be tentative, the focus being on surviving each day without raising the staff’s ire. He will be greeted cautiously, unaware of an unspoken probation, and he might only enjoy a few days’ grace before barbed remarks escape their loose restraint. Despite his commitment, he will be slow, never having had the benefit of observing local protocol as a student or a subintern. Despite having passed his exams, he will hesitate with most tasks, including the essential ones of documenting directions, checking blood tests and making a physiotherapy referral, because he is a stranger to them all. Some doctors and nurses might lend a kind and guiding hand, but he is more likely to (over)hear the following: “You are the resident — it’s your job!” “Why do I always end up with the AMCs?” “He might be a nice person, but he doesn’t have a clue!”. Occasionally, the remarks will be deliberately hurtful: “Excuse me, this desk is for doctors only!” “Why don’t they just go back where they came from?”.

He is most likely to miss tutorials because of unfinished work, and, when he does get to one, he is the diminutive figure in the corner, too self-conscious to ask a legitimate question. He is the one you will see biting on a stale sandwich most evenings as he ploughs through piles of paperwork between braving phone calls to the registrar, irate at his inability to articulate a problem in 30 seconds. When the desperately needed interpreter is hours away, he will meekly announce his grasp of two other languages. Relief and gratitude on the part of the staff will be somehow inexplicably replaced by righteousness. “At least he can do that!”

He will often wonder why his best attempts to contribute meaningfully seem antagonistic, why there is such a glaring lack of encouragement, and why he is finding this initiation harder than he had ever imagined. In a private wish list, he craves for a little more understanding and a little less hostility; then, scoffing at such imagined luxuries, he returns to face another day. Slowly, one unit then another shares the AMC burden, each one “preparing” the next, so that his perceived shortcomings always precede him. Soon he must think about the following year’s jobs. What should he do? Who knows him well enough to provide the references? Who are his role models? Should he follow the majority of his AMC peers and enrol in general practice training or should he make a concerted attempt to pursue a long-desired specialty? The obstacles seem magnified in advanced training. Even if he manages to enter a specialty program, who will supervise the children’s homework? Who in the hospital appreciates the needs of an older foreign doctor, also a son, father, husband and small business owner? The conflict between personal aspirations and life’s larger concerns routinely ravages his mind.

In the course of our own training, we have been frequent witness to, and no doubt creators of, the hurdles that the medical community puts in the way of foreign medical graduates. These hurdles are not only academic, but also personal, based on our uninformed and unchallenged perception of their culture, education and work ethic. Every foreign graduate we have taught has understood the rationale for an Australian exam, but, after attaining the very standard demanded by the profession, it is the indignity of working in an unsupported and hostile environment as a second-class doctor that turns out to be the insurmountable hurdle.

Although the issues surrounding foreign medical graduates are genuinely difficult and bear no glib resolutions, we suggest the following considerations.

• Integrate foreign medical graduates preparing for the AMC exam into hospitals by allowing them to observe educational seminars, outpatient work and grand rounds. Knowledge of local medical practice is far more accessible in this manner than by spending countless lonely hours in the library in search of assimilation. Access should not be limited to peripheral hospitals, which are often difficult to travel to and lack consistent teaching programs.

• Expand the educational program for foreign graduates by encouraging local physicians to teach. (With the assistance of just one other colleague, each of us spent just 2 hours a week to adequately address the exam syllabus.) It is crucial that program directors sanction such activity rather than be dismissive of its goals — a volunteer teaching program will enjoy success only if personal gain is sometimes set aside.

• Assign a specific mentor for foreign doctors at each institution. Such a mentor must be sensitive to the different goals and needs of foreign doctors compared with those of their local counterparts. Neither excessive pressure to conform nor total immunity from compliance with local standards should take the place of a deliberate process of integration.

• Practise what we preach. Medical students are taught from inception about the value of empathy and communication. We repeatedly examine their grasp of such skills, yet, once they are doctors, these skills are perceived to be an optional extra. Apply the open-ended question to foreign doctors: “Tell me how you feel.”

• Appreciate the worth of foreign doctors as a pillar of our increasingly cosmopolitan society. The very doctors we may deride will go on to serve entire populations, which the average Australian graduate is ill-equipped, and hence uncomfortable, to serve. The statistics on migrants, ageing populations and chronic illnesses do not bear repetition, but the overwhelming need to help our foreign doctors to help us take care of all our patients does.

In medicine, the road is long for us all, but for the foreign medical graduate it is inevitably more winding and rough. It is our obligation to not abandon our colleagues along the way, but to seek to ease their journey with small, personal gestures and larger, administrative measures. While they tend our society’s sick, we must not deny them their own bruises that often lie just beneath the surface. It is only then that as physicians we can truly call ourselves healers.