Migration and professional mobility: Rural attraction and retention of South African educated physicians.

Rural communities in Alberta, Canada have faced physician shortages for decades. Attracting internationally educated physicians, including many South African physicians, is one way to address this problem. While much of the research on international medical graduates (IMGs) focuses on the push and pull of attraction and retention, I situate the decision to stay as a matter of geographic and professional mobility, all within a life course perspective. More specifically, I explore physicians' decisions to migrate from South Africa to rural Alberta and the impact of professional mobility on their migrations. To understand the processes, I collected data via semi-structured virtual interviews with 29 South African educated generalist/family physicians with experience in rural Alberta. Research was guided by abductive grounded theory and data was analysed using open thematic coding. I found that South African educated physicians made the decision to leave South Africa and to come to Canada to pursue prestige and opportunity they perceived to be inaccessible in South Africa. However, physicians were limited to perceived low prestige work as rural generalists, while they understood that more prestigious work was reserved for Canadian educated physicians. Physicians who remained in rural communities brought their aspirations to life, or achieved upward professional mobility in rural communities, through focused clinical and administrative opportunities. The decision to leave rural communities was often a matter of lifestyle and burnout over prestige.

How the training pathways and capacity of rural physicians inform their scope of practice: A qualitative study examining the experiences of Australian and international medical graduates in South-East New South Wales, Australia.

INTRODUCTION: Current strategies to address shortages of rural doctors focus on developing a pipeline for rural generalist practice. Limited research has explored how doctors' professional journey engenders the skills required to practice rurally. OBJECTIVE: This paper analyses how rural general practitioners' clinical pathway informs their scope of practice and future retention. DESIGN: Qualitative thematic analysis using semi-structured telephone interviews. Twenty-one general practitioners appointed in their local health district of Murrumbidgee and Southern New South Wales, Australia, within the past 10 years. Participants comprised 10 Australian medical graduates (AMG) and 11 international medical graduates (IMG). FINDINGS: AMGs and IMGs contrasted how their pathway into rural practice, and capacity to work rurally, informed their scope of practice. Australian medical graduates' familiarity with rural areas was consolidated through congruous experiences, including at rural clinical schools. Paradoxically, the fluency of their training limited the amount of unsupervised experience and confidence AMGs gained. Together with a focus on work-life balance, this limited many to providing mainstream general practice, precluding extending their scope of practice. International medical graduates described disseminated experiences, often unsupervised in high-volume contexts. However, a lack of professional opportunities prevented them from extending their scope of practice. DISCUSSION: IMG and AMG motivation and pathway for working rurally differ. Respective cohorts have concerns regarding requisite skills and knowledge for rural practice, which incorporates opportunity and recognition. Entry points for training should be variable to allow consideration of life stage, prior skill development and extension of scope of practice. CONCLUSION: Doctors' scope of practice is informed by their pathways into rural practice. Australian medical graduates may not gain adequate competence during expedited training programs to confidently undertake extended clinical activities. International medical graduates, however lacked the opportunities and support, to utilise their expertise in rural practice. Complementarily utilising the expertise and commitment of both AMGs and IMGs may synergistically address workforce shortages.

Cross-cultural code-switching - the impact on international medical graduates in New Zealand.

BACKGROUND: New Zealand relies on International Medical Graduates (IMGs); however, the retention of IMGs is not optimal. This research uses a lens of cross-cultural code-switching to explore how professional and cultural differences impact on International Medical Graduates' (IMGs') journeys to practise effectively and remain in New Zealand. METHODS: Utilising theory-informing inductive analysis within a constructivist approach, framework analysis was conducted following 14 face-to-face interviews with IMGs. The analysis then explored the degree to which their experiences could be explained by cross-cultural code-switching's psychological challenges (authenticity, competence, and resentment). RESULTS: Analysis showed there was an expectation for IMGs to code-switch. The greater the cultural and professional difference of IMGs (compared to New Zealand), the greater the intensity of psychological challenges experienced when switching. Moreover, IMGs received minimal support, making it difficult to overcome psychological challenges, especially the competence challenge. This led to feelings of frustration and vulnerability. Code-switching could also explain why complaints about IMGs were more likely when IMGs were stressed or tired. CONCLUSION: Cross-cultural code-switching can be used to explain and identify how cultural differences cause psychological challenges. These findings inform how programmes can better support IMGs in orientation and ongoing training. Additionally, establishing, and allocating IMG cultural mentors would assist in addressing IMGs' vulnerability and isolation. With this support, the journey may prove more manageable and encourage IMGs to continue practising in their adopted country.

Asian medical students' attitudes towards professionalism.

Background: Professionalism is the basis of trust in patient-physician relationships; however, there is very limited evidence focusing on attitudes towards professionalism among medical students. Hence, the main aim of our study was to investigate Malaysian medical students' attitudes towards professionalism with specific emphasis on the comparison between pre-clinical and clinical students. Our secondary aim was to compare the differences in perception of medical students in Malaysia (pre-clinical and clinical) with Asian medical students studying in Dublin, IrelandMethods: This study utilized the Professionalism Mini-Evaluation Exercise (P-MEX) instrument which consists of 25 items that represent four skill categories: Doctor-Patient Relationship skills, Reflective skills, Time Management and Inter-Professional Relationship skills. Descriptive statistics were used to describe the demographic information of students and given the ordinal nature of the data, Mann-Whitney U-tests were used.Results: Overall, students have positive attitudes to all the professionalism items with more than 80% of the students agreeing that each of the professionalism attributes is important or very important. There was evidence of a significant difference between Malaysian pre-clinical and clinical students in relation to 'avoiding derogatory language' only (p = 0.015). When comparing between Malaysian and Dublin Asian students, there was a statistically significant difference in relation to 'show interest in patient as a person' (p < 0.003) for clinical students.Conclusion: Our results point to several curriculum implications such as 1) assessing students' attitudes towards professional attributes is essential when developing the professionalism curriculum, 2) integrating more effective clinical modules early in the curriculum and 3) considering geographical and cultural factors when assessing perception towards professional attributes.

African Physician Migration to High-Income Nations: Diverse Motives to Emigrate ("We Are not Florence Nightingale") or Stay in Africa ("There Is No Place Like Home") Comment on "Doctor Retention: A Cross-sectional Study of How Ireland Has Been Losing the Battle".

Research in assessing the global and asymmetric flows of health workers in general, and international medical graduates in particular, is fraught with controversy. The complex goal of improving health status of the citizens of home nations while ensuring the right of health workers to migrate generates policy discussions and decisions that often are not adequately informed by evidence. In times of global public health crises like the current coronavirus disease 2019 (COVID-19) global pandemic, the need for equitable distribution and adequate training of health workers globally becomes even more pressing. Brugha et al report suboptimal training and working conditions among Irish and foreign medical doctors practicing in Ireland, while predicting large-scale outward migration. We comment on health personnel migration and retention based on our own experience in this area of research. Drawing from our examination of medical migration dynamics from sub-Saharan Africa, we argue for greater consideration of health workforce retention in research and policy related to resource-limited settings. The right to health suggests the need to retain healthcare providers whose education was typically subsidized by the home nation. The right to migrate may conflict with the right to health. Hence, a deeper understanding is needed as to healthcare worker motives based on interactions of psychosocial processes, economic and material determinants, and quality of work environments.

What influences trainee decisions to practise in rural and regional Australia?

Although international medical graduates (IMGs) make up a substantial part of the Australian rural general practice workforce, most research on factors associated with rural practice has focused on Australian medical graduates (AMGs). This study aimed to determine whether there were differences between IMGs and AMGs in terms of these factors. Registrars in training and recent fellows (Fellowship of the Royal Australian College of General Practitioners/Fellowship of the Australian College of Rural and Remote Medicine) who participated in training in rural and regional Australia were surveyed about practice models and rural practice. Almost two-thirds of participants were practicing or intending to practice in rural areas, with no difference between AMGs and IMGs. None of the variables associated with rural practice for AMGs was found to be associated with rural practice in IMGs in univariate binary regression analysis. Two key variables that are strongly associated with rural medical practice in the current literature, namely rural background and rural exposure, were not significant predictors of rural practice among IMGs. Due to the significant number of IMGs in regional training programs, any future incentives designed to improve rural recruitment and retention need to address factors relevant to IMGs.

Investigating competencies needed by European-trained doctors in rural South African hospitals.

BACKGROUND: Many European-trained doctors (ETDs) recruited to work in rural district hospitals in South Africa have insufficient generalist competencies for the range of practice required. Africa Health Placements recruits ETDs to work in rural hospitals in Africa. Many of these doctors feel inadequately prepared. The Stellenbosch University Ukwanda Centre for Rural Health is launching a Postgraduate Diploma in Rural Medicine to help prepare doctors for such work. AIM: To determine the competencies gap for ETDs working in rural district hospitals in South Africa to inform the curriculum of the PG Dip (Rural Medicine). SETTING: Rural district hospitals in South Africa. METHODS: Nine hospitals in the Eastern Cape, KwaZulu-Natal and Mpumalanga were purposefully selected by Africa Health Placements as receiving ETDs. An online survey was developed asking about the most important competencies and weaknesses for ETDs when working rurally. The clinical manager and any ETDs currently working in each hospital were invited to complete the survey. RESULTS: Surveys were completed by 19 ETDs and five clinical managers. The top clinical competencies in relation to 10 specific domains were identified. The results also indicate broader competencies required, specific skills gaps, the strengths that ETDs bring to South Africa and how ETDs prepare themselves for working in this context. CONCLUSION: This study identifies the important competency gaps among ETDs and provides useful direction for the diploma and other future training initiatives. The diploma faculty must reflect on these findings and ensure the curriculum is aligned with these gaps.

International Medical Graduates: Promoting Equity and Belonging.

International medical school graduates (IMGs) play a vital role in the health care system of the United States. They constitute roughly one-quarter of the physician workforce, comprising a significant proportion of the primary care providers in high-need rural and urban areas, where they provide equal and, in some instances, better care than U.S. graduates. Nonetheless, they face a series of hurdles in entering U.S. residency programs and throughout their training experiences.IMGs must expend significant resources to obtain Education Commission for Foreign Medical Graduates certification, which includes Steps 1, 2 Clinical Knowledge and 2 Clinical Skills of the United States Medical Licensing Examination. They encounter the uncertainty of matching and, if successful, obtaining a visa to enter the United States. Once here, they need to adapt to the complexities of the health care system and familiarize themselves with the cultural nuances, professional behaviors, and communication skills of another country. They encounter biases and microaggressions and lack support groups and mentors. Those who choose an academic career are less likely to obtain leadership positions.This Perspective provides an overview of these challenges and highlights opportunities for change at local and national levels. Specifically, it identifies strategies that would assist IMGs before entry, at entry, during training, at the transition to practice, and in practice. The current COVID-19 pandemic highlights the shortage of physicians in the United States and illustrates the importance of ensuring that IMGs, who are essential health care workers, feel welcome, valued, and recognized for their contributions.

The role of virtual sub-internships in influencing career perceptions: an international medical graduate perspective.

The SARS-CoV-2 pandemic has left a huge impact on the career perceptions of trainees and medical students globally. The cancellation and/or replacement of sub-internships in the United States (US) with a virtual alternative offer a different experience. We explore the impact of this issue on international medical graduates (IMGs) who are planning to apply to a US residency program in the near future.

To stay or go? Unpacking the decision-making process and coping strategies of International Medical Graduates practising in rural, remote, and regional Queensland, Australia.

Australia is one of many countries to rely on International Medical Graduates (IMGs) to fill general practitioner (GP) positions throughout its regional, rural, and remote (RRR) communities. Current government initiatives requiring IMGs to work for specified periods in RRR areas offer only short-term solutions. The need to improve the long-term retention of IMGs practising in RRR areas has motivated this research to improve our understanding of how IMGs make decisions about where to practise. Specifically, this study sought to: (a) identify the factors that influence an IMG's decision to remain working in RRR areas, and (b) develop a theory, grounded in the data, to explain how these factors are prioritised, evaluated and used to inform a decision to remain working in RRR areas. This study adopted a qualitative approach and employed grounded theory methods. Data collection and analysis occurred concurrently, using constant, comparative analysis, guided by theoretical sampling and data saturation. Data sources were transcripts from semi-structured interviews with IMG registrars (n = 20) and supervisors (n = 5), interviewers' notes and analytic memos. Interviewees were all currently working in RRR areas of Queensland, Australia. The analysis involved a three-phase coding process, progressing from specific, inductive coding to abstract, abductive coding. The analysis revealed that the IMG decision-making process involves a complex, dynamic, and iterative process of balancing life goals based on life stage. Many factors are considered when assessing the balance of three main life goals: satisfaction with work, family, and lifestyle. The prioritisation and balance of these life goals can vary as the IMG moves through varying work-, family-, and age-related life stages. It is hoped that having this understanding of the complexity of the IMG decision-making process, will better equip medical educators, policy makers and support service providers to tailor services to encourage IMGs to continue practising in these regions.

'Everything was just getting worse and worse': deteriorating job quality as a driver of doctor emigration from Ireland.

BACKGROUND: Medicine is a high-status, high-skill occupation which has traditionally provided access to good quality jobs and relatively high salaries. In Ireland, historic underfunding combined with austerity-related cutbacks has negatively impacted job quality to the extent that hospital medical jobs have begun to resemble extreme jobs. Extreme jobs combine components of a good quality job-high pay, high job control, challenging demands, with those of a low-quality job-long working hours, heavy workloads. Deteriorating job quality and the normalisation of extreme working is driving doctor emigration from Ireland and deterring return. METHODS: Semi-structured qualitative interviews were conducted with 40 Irish emigrant doctors in Australia who had emigrated from Ireland since 2008. Interviews were held in July-August 2018. RESULTS: Respondents reflected on their experiences of working in the Irish health system, describing hospital workplaces that were understaffed, overstretched and within which extreme working had become normalised, particularly in relation to long working hours, fast working pace, doing more with less and fighting a climate of negativity. Drawing on Hirschman's work on exit, voice and loyalty (1970), the authors consider doctor emigration as exit and present respondent experiences of voice prior to emigration. Only 14/40 respondent emigrant doctors intend to return to work in Ireland. DISCUSSION: The deterioration in medical job quality and the normalisation of extreme working is a key driver of doctor emigration from Ireland, and deterring return. Irish trained hospital doctors emigrate to access good quality jobs in Australia and are increasingly likely to remain abroad once they have secured them. To improve doctor retention, health systems and employers must mitigate a gainst the emergence of extreme work in healthcare. Employee voice (about working conditions, about patient safety, etc.) should be encouraged and used to inform health system improvement and to mitigate exit.

The turnover intentions and intentions to leave the country of foreign-born physicians in Finland: a cross-sectional questionnaire study.

BACKGROUND: A physician shortage is a worldwide problem and foreign-born physicians fill in the shortage of physicians in many developed countries. One problem that is associated with the physician shortage is increased physician turnover. Also, regarding foreign-born physicians, migration can be costly. The present study aimed to examine the turnover intentions and intentions to leave the country of foreign-born physicians. We examined how demographics, discrimination, language problems, perceived employment barriers, satisfaction with living in Finland, team climate, job satisfaction and patient-related stress were associated with these factors. METHODS: The present study was a cross-sectional questionnaire study among 371 foreign-born physicians in Finland that were aged between 26 and 65 (65% women). Binary logistic regression analyses were conducted to examine the associations. RESULTS: Half of the respondents had turnover intentions and 14.5% had considered leaving the country. High satisfaction with living in Finland was associated with a lower likelihood of both turnover intentions and intentions to leave the country. High levels of discrimination and employment barriers were associated with a high likelihood of turnover intentions whereas good team climate was associated with a low likelihood of turnover intentions. High levels of language problems were associated with a high likelihood of intentions to leave the country. CONCLUSIONS: The present study showed the importance of satisfaction with living in the host country, the prevention of discrimination and employment barriers, language skills and a good team climate for the retention of foreign-born physicians in their current job and in the host country. Thus, to keep their foreign-born physicians, health care organisations should implement measures to tackle these challenges. Organisations could arrange, for example, diversity training, self-assessment, team reflections, leadership coaching and culturally-specific networks. Moreover, internships associated with the qualification process could be utilised better in order to give a thorough introduction to the host country's health care environment and the possibilities for learning the language.

Where are they working? A case study of twenty Cuban-trained South African doctors.

BACKGROUND: The year 2017 marked the 21st anniversary of the South African Cuban Medical Collaboration (SACMC) programme that offers disadvantaged South African (SA) students an opportunity for medical training in Cuba. Graduates are expected to return to practice at a primary care level in rural communities; however, little is known about the professional trajectories and career choices of graduates from the programme. AIM: This study explored the reasons why students enrolled in the programme, their professional and career choices as graduates and their career intentions. SETTING: The study setting was the whole of SA although participants were primarily drawn from KwaZulu-Natal. METHODS: An exploratory, qualitative case study used a purposive sampling strategy to gather data through semi-structured interviews from participants. RESULTS: Graduates (N = 20) of the SACMC programme were all practicing in local SA settings. Participants preferred the SACMC programme as it offered them a full scholarship for medical training. Nineteen doctors had fulfilled their obligation to work in rural areas. Thirteen doctors are engaged in primary healthcare practice, either as private practice generalists or as public service medical officers. Three doctors had completed specialty training: one doctor was training towards specialisation, one doctor was employed at national government and two doctors were employed as medical managers. At the time of the study, 11 doctors were practicing in rural locations and 19 had indicated a long-term intention to work and live within South Africa. CONCLUSION: The participants of this study who graduated from the SACMC programme are fulfilling their obligations in rural communities. They all intend to contribute to the SA medical workforce in the long-term.

Contrasting Residency Training in Japan and the United States From Perspectives of Japanese Physicians Trained in Both Systems.

BACKGROUND: International medical graduates (IMGs) have significant exposure to clinical training in their home country, which provides opportunity for international comparison of training experiences. One relevant IMG population is Japanese physicians who have completed some training before entering residency programs in the United States and desire to improve medical education in Japan. OBJECTIVE: We examined Japanese IMGs' perceptions of the respective attributes of residency in the United States and Japan. METHODS: Individual semistructured interviews were conducted with 33 purposively sampled Japanese IMGs who had completed training. We used exploratory thematic analysis, iterative data collection, and thematic analyses with constant comparison. RESULTS: Comments were organized into 3 categories: (1) attributes of US residency preferable to Japanese residency; (2) attributes of residency training with no clear preference for the US or Japanese systems; and (3) attributes of Japanese residency preferable to US residency. Within each category, we matched themes to residency program requirements or culture of medical training. Main themes include high regard for Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements, with emphasis on efficient achievement of clinical competency through graded responsibility, contrasted with preference expressed for a Japanese training culture of increased professional commitment facilitated by a lack of work hour limits and development of broad clinician skills, including bedside procedures and radiology interpretation. CONCLUSIONS: Japanese training culture contrasts with a US model that is increasingly focused on work-life balance and associated compartmentalization of patient care. These findings enhance our understanding of the global medical education landscape and challenges to international standardization of training.

International medical graduates and general practice training: How do educational leaders facilitate the transition from new migrant to local family doctor?

Objectives: To document medical educators' experience and initiatives in training international medical graduates (IMGs) to become general practitioners (GP). Design: Qualitative social-constructivist emergent design with descriptive and interpretive analyses. Setting: GP vocational training in Australia, Canada, Ireland, New Zealand, the Netherlands, and UK. Participants: Twenty-eight leaders of GP training. Intervention: Data collected from public documents, published literature and 27 semi-structured interviews. Main outcome measures: Tensions in training and innovations in response to these tensions. Results: Medical educators identified tension in teaching IMGs as it could be different to teaching domestic graduates in any or all aspects of a training program. They felt an ethical responsibility to support IMGs to provide quality health care in their adopted country but faced multiple challenges to achieve this. They described initiatives to address these throughout GP training. Conclusions: IMG's differing educational needs will benefit from flexible individualized adaptation of training programs.

Surgical Training in South Africa: An Overview and Attempt to Assess the Training System from the Perspective of Foreign Trainees.

BACKGROUND: Currently, there are no objective reports evaluating the quality of the South African surgical training. The aim of this study is to evaluate the current state of surgical training in South Africa from an external impartial point of view and to rate the experience of short-term supernumerary registrars and fellows (STSRF) within the South African training system. METHODS: A 29-item survey was distributed via e-mail and social media to non-South African trainees who worked in South Africa as STSRF for a period of at least 1 month during the past 5 years. The survey evaluated the surgical, clinical and academic training received during their elective period in a South African department. RESULTS: Sixty-four STSRF replied to the survey. Sixty-two percent of STSRF attended a trauma unit during their experience. For the majority of respondents, open and emergency surgical exposure, as well as experience as first surgeon, is significantly higher in the South African system, while minimally invasive and endoscopic surgery exposure is significantly less. Research project involvement is significantly less, for the STSRF, as opposed to lectures and teaching that constitute a higher percentage. No significant difference was found regarding exposure to hands-on activities. CONCLUSIONS: The South African system still provides excellent surgical and clinical exposure as well as teaching. However, minimally invasive surgery training and research are generally lacking for the STSRF. Exchange programs between South African and developed country institutes should be improved and encouraged in order to gain mutual benefits.

'Standardized patients' in teaching the communication skill of history-taking to four-year foreign medical undergraduates in the department of obstetrics and gynaecology.

BACKGROUND: Many foreign students have difficulty taking histories from Chinese patients, especially in clinical context of the Department of Obstetrics and Gynaecology. The efficacy of using standardized patients to prepare foreign students for communicating with Chinese patients and taking their histories was evaluated in this study. METHODS: Ninety-four four-year foreign students were assigned to one of three clinical sub-departments (gynaecology, obstetrics, and reproductive endocrinology) to practice history-taking; after practicing in one sub-department, the students were then crossed over to a different department. The histories were taken from real patients in the sub-departments of obstetrics and reproductive endocrinology and from standardized patients in the sub-department of gynaecology. Prior to contact with real patients in the sub-department of reproductive endocrinology, the students practised with standardized patients. The quality levels of the case reports generated in the three departments were compared by repeated measures ANOVA. The attitudes, satisfaction and suggestions of the students were also investigated through a questionnaire. RESULTS: The local Chinese language spoken by the patients was thought to be the most common difficulty students (76.7%) encountered while taking patient histories. Two-thirds and one-third of the students were interested in taking histories from standardized and real patients, respectively. Most students (94.2%) thought that working with standardized patients was useful for practising communication skills with Chinese patients. The total scores of the case reports were significantly different among the three groups (P < 0.001), and compared with case reports collected from real patients, case reports collected from standardized patients were of better quality. However, the quality of the case reports taken from real patients was better when the case reports were generated by students who had previous practice with standardized patients than when they were generated by students lacking such experience (P < 0.001). CONCLUSIONS: Standardized patient training for practising history-taking can be included as part of the clinical training curriculum for foreign medical undergraduates in the Department of Obstetrics and Gynaecology in China.