To the Editor: The review of issues faced when training international medical graduates (IMGs) by Pilotto and colleagues is indeed timely.1 Their systematic presentation of these issues resonates loudly with many of the daily challenges of hospital practice.

While their review referred to the shortfall of doctors, it failed to emphasise how critical this shortfall already is in some areas of hospital practice. As workloads escalate, IMGs increasingly underpin the provision of critical care clinical services. Among trainees in my department, the rise in the proportion of IMGs whose first language is not English has been dramatic, increasing from 22% of trainees in 2000 to 83% in 2007 (Box).

In my experience, these doctors arrive with high expectations of the system that will train them to be critical care specialists, and place enormous pressure on themselves to achieve this. IMGs with English as a second language require greater early supervision to orient them to differences in hospital systems and language. Later, they require more assistance in preparing for the Fellowship examinations than IMGs whose first language is English. Between 2000 and 2007, an increasing clinical workload has left less time and resources for their training, and currently the needs of these IMGs are often not being met. These doctors are crucial to the provision of clinical services in our hospital, and their needs should not be ignored. Anecdotally, we are already seeing IMGs previously desperate for any training position now “cherry picking” hospitals with better resourced training programs.

On average, compared with Australian medical graduates, IMGs with English as a second language spend longer in Fellowship training programs and are more likely to reattempt examinations; and the registration, training and examination fees for IMGs are considerable. The specialist medical colleges should already be in a position to fund initiatives for IMGs whose first language is not English. However, regrettably, as far as I am aware, they receive no specific help in undertaking the language-rich examination process for a Fellowship in critical care medicine.

When I reflect on my specialty training, the thought of having to pursue this in an unfamiliar language is overwhelming. Not surprisingly, IMGs constantly perform under the pressure of “not measuring up”. Their appreciation of the help and training they receive is immense. However, I think one of my more important tasks as Supervisor of Training, particularly early in their training, is to remind IMGs of the great clinical work they perform day in, day out. The debt we owe them is also immense — who needs whom the most?

Number of critical care trainees at Flinders Medical Centre, Adelaide, South Australia, 2000–2007, by origin and English-speaking status

IMG = international medical graduate.