Walking a mile in their shoes: reflections on being an international medical graduate

A comprehensive orientation process is essential in assisting international doctors to adjust to life in a new country

International medical graduates (IMGs) remain a crucial part of our general practitioner and specialist workforce, with many working in rural and remote locations.1 With the rapid pace of globalisation in health care, the traffic in health graduates across the globe is destined to continue and expand. The World Health Organization has developed a code of conduct for use by participating countries.2 A recent experience — as a pair of IMGs working for 12 months in rural British Columbia in Canada in 2015 — caused serious reflection on the often unrecognised stress our colleagues face when they make the momentous move “Down Under”. I was offered a position in a small community of 6000 people with a visiting medical officer role at the hospital and responsibilities of office-based general practice. Understanding the professional medical role of a doctor is but one of the adjustments to be made in a new country with new processes, cultural norms, expectations and issues, such as very cold weather and large predatory animals (Box).

My own experience in seeking registration in Canada was that the process was far lengthier than I imagined, with a lead time of 2 years to collect qualifications and justify and work through the many layers of review required for professional registration before arriving in the country. At the same time, visa processes had to be commenced separately and were often conditional on achieving progress on registration. While there is much variation, this sort of lengthy period to achieve the visa and compliance is likely similar for IMGs commencing in Australia. Thus, by the time we arrived in Canada to commence the next round of in-country paperwork and compliance, I was already fatigued by the process. Achievement of a work permit, in my case, required three trips to the Canadian border because of an administrative glitch in the data entry of a compulsory medical exam. The knowledge that registration is conditional on working in a “hard to staff” location (ie, a district of workforce shortage) and the continuing conditions on registration until having sat the requisite exams remained an ongoing professional and financial stress.

Moreover, the language difficulties, even in an English speaking country, were a continuing cause of delay and misunderstanding. Terms such as reciprocal recognition of qualifications mean different things in different jurisdictions. Dates, for instance, could be written into forms in different ways (eg, 10/3/2016, 2016/3/10 or 3/10/2016), invalidating documents if wrong. Doses of commonly used drugs were not uniform between countries, and even generic prescriptions did not always ensure comparable products due to different formulations.

I was also unaware of the power imbalance and implications when a clinical supervisor had the direct capacity to influence the continuance of your visa. A negotiation about wages and conditions would be coloured by the reality that putting your supervisor offside could result in the inability to remain in the country. When families are dependent not only on the income of the IMG, but also on the ability to stay in the country, there is nothing to be done other than accept whatever arrangements are put forward. This combined financial and professional indenture would have mitigated for some people against the negotiation of mutually suitable working conditions, holidays or work–life balance.

Some simple strategies would have assisted me, and I suspect would be useful for IMGs moving to Australia. First, an appreciation of the stress, fatigue and loneliness of moving and adjusting to life in a new country would be beneficial. Pairing IMGs with mentors for education, financial matters (such as dual taxation) and also for pastoral care, separate from the supervisory relationship with an employer, may allow IMGs to more honestly negotiate the challenges of living as well as working. The vulnerability of individuals and families with no community supports, who are under significant stress, should be recognised and a non-judgemental confidential support system encouraged.

Orientation is clearly very important, but needs to be a process not a one-off event.3 Orientation should encompass the funding and systemic linkages in the health system, expectations of the professional roles to be undertaken and clear information about behavioural and cultural norms in the local community.4 Advice about the locality, including safe and unsafe neighbourhoods and important anniversaries and cultural days, is also essential. Information provided in the first weeks may need to be repeated and reviewed when the IMG is starting to encounter new situations or is required to use the processes and electronic records. I found that the best orientation information was gained after I had tried to dictate a discharge summary, ring a colleague and work out the billing. Positive initial experiences, including orientation, are likely to enhance long term workforce retention. Most IMGs are recruited to areas of existing workforce shortage and areas which have had trouble attracting Australian graduates. A comprehensive holistic approach to IMG recruitment will consider their needs as well as their value as a medical professional.5

Recognition of some of the difficulties of working and living in small rural communities, coupled with approaches to support IMGs and families, will be an investment in happier, healthier valued medical professionals.

Box – Warnings on Fraser Canyon Hospital door