International medical graduates (IMGs) are individuals who train and receive their medical education and some part of their training in one country and then move to settle down in another country. Although doctors from high-income countries may move to other high-income countries, for example, from the United States to Canada or to Australia, the movement is largely from low- and middle-income countries to high-income countries. Trainees who have completed their basic medical training in medicine in a low- and middle-income country may move because there may be limited training opportunities in the field of their choice. They may choose to move to high-income countries such as the U.S., U.K., Australia, or Canada for better academic facilities and to learn and work in technologically advanced and sophisticated healthcare systems. For example, over 35,000 medical students graduate each year in India, but only 266 training posts are available in psychiatry (1). Thus, a disparity between training-places and numbers applying may push IMGs toward other training-places. This creates a group of trainees who may migrate with a short-term period in mind, but choose not to return for personal, financial, and academic reasons. The past few decades have seen a large number of students moving to economically stronger settings, initially, in pursuit of higher education and, subsequently, to stay on for better job opportunities. On the other hand, healthcare crises—particularly in recruitment and retention in high-income countries, along with increased demands—will inevitably affect the healthcare workforce in other nations around the world. This was exemplified by the actions in the U.K. a few years ago, when the U.K. government, in order to meet its election promises to have more doctors and healthcare staff, sent “ambassadors” to recruit senior trained psychiatrists from the Indian subcontinent in order to fill unattractive and difficult-to-fill posts, thereby denuding many academic departments in India. Political imperatives expressed by the then-government led to positive recruitment from countries that could ill afford to lose fully-trained individuals. Therefore, this second group may constitute IMGs who are already fully trained and may be attracted by better working conditions and/or better technological facilities and are pushed out for economic and political reasons.
It is inevitable that these two groups will experience different kinds and different levels of stress related to reasons for migration and expectations from the new country.
This paper highlights the migratory experiences of IMGs specializing in psychiatry who move from one country to the other, the various stresses they face, and the coping mechanisms they use to deal with these stresses. In this context, IMGs are doctors who have graduated from their country-of-origin and migrated to another country.
As is evident from the above, like other migrants, IMGs also migrate in response to “push and pull” factors shown in Table 1.
TABLE 1.Factors Leading to Migration of Psychiatric Graduates From Developing to Developed Nations
| Add to My POL
|Pull Factors||Push Factors|
|• Better education facilities|| • Poor education and healthcare system|
|• Better healthcare systems and networks|| • Limitations in specialty training and number of available posts|
|• Need for international exposure|| • Scarce job opportunities, with low wages|
| • Globalization and urbanization|
| • Job opportunities|
To reiterate, “Push” factors include poor training opportunities and limited resources for personal and professional development, thereby pushing individuals away. Although, as noted earlier, trainees may move for training and further education, but, having spent time in the new system may make them feel inadequate or ill-prepared in the old system, creating further reasons for not returning. In countries like India, positive discrimination in favor of certain groups on the basis of caste works as a major disadvantage for others, who may then choose to leave if they see their progression being blocked. A well developed healthcare network and relevant structures in these developed nations may thus appear to be an extremely attractive factor. This would be a “pull” factor; and poor resources in their country-of-origin may act as a “push” factor.
“Pull” factors may be seen as attractive, providing largely financial and personal rewards. Some factors can obviously work both as Push and Pull factors; however, as, for example, personal and professional development or family growth and development. Learning about new therapeutic techniques can also work as both a Push and a Pull factor.
Urban areas have reported higher rates of many psychiatric disorders (2, 3), and this will inevitably increase demands for better human resources, adding another Pull factor. Changing demographic structures around the globe and increasing demands on finite resources will also act as Pull factors. From an economic perspective, importing fully-trained professionals from low- and middle-income countries becomes an attractive option for developed countries, as they do not have to spend money on basic training. Consequently, under these circumstances, countries with better financial incentives will be more successful in pulling staff, thereby creating imbalances in the global situation (4).
It is likely that trainees may be migrating as a result of Push factors, and fully trained individuals may be moving in response to Pull factors, although such a clear distinction is not always possible. Thus, there will also be an age and experience differential between the two groups. There are similarities of experience within the groups, no matter where they migrate from, as evidenced by Verghese’s autobiographical journey (5). It is inevitable that age will play a key role in the process of preparation and subsequent adjustment. Younger individuals may find it easier to adjust in the new system, especially as they are likely to be more flexible and willing. Older individuals may have become used to working in one system and may find it difficult to change their workstyle and habits.
Other factors that may play a role include the availability of human resources in other disciplines. There is anecdotal evidence to suggest that many countries, including the U.K., are facing recruitment shortages in psychiatry, and this has been blamed on tighter visa restrictions. There are recruitment and retention challenges in many countries.
Balon et al. (6) noted that the number of psychiatrists being produced in the United States is declining. Cooper (7) had also warned of a progressively increasing “severe” shortage of specialists and, especially, of psychiatrists in the United States (8), which would increase the dependence on IMGs to “fill the gap.” In the U.K., migration from within the EU may well increase, to provide adequate human resources.
It is clear that, like all migrant groups, IMGs are also a heterogeneous group, coming from diverse cultural, linguistic, and medical education backgrounds, but they play a key role in the delivery of healthcare services. Often, they will be working in unpopular specialties and with underserved populations in the new country (9). Rao et al. (9) emphasize that IMGs form a significant part of the workforce in the U.S., and they face unique challenges. Politicians often raise the specter of the impact of high levels of migration upon the native workforce, but, in many Western countries, countless services would collapse were it not for the staff from abroad—the IMGs.
The World Health Organization (WHO) (10) recognizes human resources for health as “the most important component of the healthcare delivery systems. Human resources are a major aspect of key measurements of a health system’s ability to combat health crises and build sustainable health systems in all countries (11). Like other parts of healthcare delivery, demands on mental health systems have also grown, along with the stresses on their human resources (12).
Moving from one’s home to a new place of residence can lead to stress and have a destabilizing effect upon an individual (13, 14). Stress can be related simply to being in a new job and setting; or it may develop as an acculturative process, in adjusting to a broader culture. Acculturative stress is a reflection of difficulties in adjustment to the new culture, new work settings, patterns of work, different healthcare system, and, perhaps, a new language. These stresses are shown in Table 2. A key factor, which is often ignored in practice but may play a significant role in dealing with stress, is the discrepancy between aspiration and achievement. Like other migrants, IMGs may have high expectations and aspirations that they may not be able to fulfill. This discrepancy will affect their self-esteem. Their experiences are no different from those of other migrants, except that, because of high professional education and training, their aspirations may be greater, as more-educated professionals would expect better status.
TABLE 2.Sources of Stress for IMGs in the Process of Moving From the Native Country to the Host Country
| Add to My POL
| • Managing finances to fund frequent trips and complete education|| • Undergoing the formalities of migrating, such as visas, etc.|| • Migratory stress|
| • Dealing with entrance and qualifying processes and examinations|| • Clearing through the immigration process|| •Culture shock and acculturation problems|
| • Waiting for the results|| • Separation from family and loved ones|| • Lack of social support|
| • Gaining admission into a higher ranking institution|| • Drastic change in education and health systems|
| • Waiting period until the next admission session if unsuccessful the first time|| • Language barriers|
| • Ethnic-minority prejudice and discrimination issues|
| • Managing finances|
| • Dealing with competition|
| • Adjusting to “psychiatric culture” of the host country|
It is worth understanding the processes of adjustment by looking at stages of migration. The three stages are-pre-migration, migration, and post-migration.
This is the period before actual migration, and it may vary from weeks to years. Preparation for migration will be influenced by a number of factors, such as the personality of the individual; social support available; time available for learning about and preparing for the act of migration; familiarizing oneself with the new culture; becoming proficient in the new language, if required; and reasons for migration. Political reasons for migration, such as war or running away from conflict or difficulties caused by political beliefs, will not only produce considerable problems before actual migration, but will also cast a long shadow over the individual and his or her family after migration. This preparation period requires the individual to consider funding possibilities, fees required for different courses, visa formalities, and preparations for travel and climate conditions, and so on. Appearing for the qualifying entrance examinations and then waiting for the results may well be stressful in itself, as career progression clearly hinges on this. IMGs may aspire to gain admission for training or employment into highly competitive reputable organizations; not achieving this will add to alienation and stress.
As a result of migration, loss of various kinds is inevitable, but separation from friends and family, with its accompanying loss of social support, may increase stress and lead to difficulties in acculturation and adjustment.
The actual physical process of migration itself may be stressful for some individuals, but not for others. This stage involves the actual physical relocation from one country to another. Managing employment, visa, travel, and arrival can all play a role in developing stress.
In the post-migration period, again, the adjustment may take months to years. Key factors in this stage include the following:
Acculturation is one of the key processes in adjusting to a new culture. This is the process where two cultures come into close contact, and individuals from one culture learn and accept some aspects about the new culture, but may also choose to ignore other of its aspects. There are various types of acculturation; these include assimilation, de-culturation, marginalization, and acculturation. De-culturation is the process by which individuals lose their own culture completely because of the overpowering nature of the new culture, largely as a result of conflict. Acculturation may lead to biculturalism, where individuals may feel equally comfortable in both the cultures. However, the individual and group identities as part of the process must be taken into account. Inevitably, acculturative process relies on factors such as age; education; gender; nature of migration (voluntary or forced; whether the individual is a primary migrant or a solo migrant); personality, social, personal, and financial resources, and so on. Some IMGs may well experience culture-shock in the process, especially if they need to learn and work in another language and system. IMGs, especially those from Asia and the Middle East, may face problems in adjusting to Western cultural values (15), bearing in mind that cultures are not homogeneous. Apart from cultural adjustments, IMGs may have to adjust to differences in learning, communication, and functioning styles, as individuals across different ages do (15, 16). Rojas et al. (17) demonstrated that U.S. medical graduates (USMGs) and international medical graduates (IMGs) differ in their preparedness for systems-based and practice-based learning. These differences may contribute to a sense of bewilderment and resulting culture-shock.
Also, IMGs may have to cope with differences in the communication styles between educators and patients (18), which are attributable to language and cultural differences, and add another dimension to acculturation. Some IMGs may have a limited command of the English language. They may have acquired their training in their primary language, thus forming one of the three most difficult barriers to their acculturation, along with economic and migration issues (13, 18). It is likely that a weakness in language can pose a barrier not only to adjustment and acculturation but also to learning and, most importantly, to communication with patients and their families, as well as with the public at large, which is at the heart of practice of psychiatry. Also, problems related to language, along with a lack of knowledge of local cultural norms, can create therapeutic non-adherence and, in some cases, even conflict in the therapeutic relationship. Establishing rapport with patients and carers and matters dealing with confidentiality vary across cultures. In some cultures, the patient may be accompanied by a group of carers, and the psychiatrist may be used to assessing and sharing information in a more public manner. This approach may cause problems in Western countries, where patient confidentiality is of paramount concern and relies on the individual patient’s permission to share information.
Pilotto et al. (18) demonstrated how establishing rapport with patients was a challenge for IMGs in Australia. Their sample had been trained in non-Western countries, and this led to frustration on the part of patients. In some cultures, patients expect and willingly accept direction, direct interventions, and information, whereas,, in others, patients expect to be treated as equal partners in decision-making. Similarly, in some countries, multidisciplinary staff do not have a status equal to that of the doctor, and moving to places where this is the norm can come as a shock to many IMGs. It is thus crucial that they learn quickly how to work with patients, families and colleagues. Hall et al. (19) also note that a less hierarchical healthcare system, such as the Canadian one, will inevitably have an impact on the style of communication, and therefore issues related to hierarchy, gender, power, and roles within the team will come into play, and the IMG may not be able to handle these.
As noted above, the issue of confidentiality has sometimes created conflict. In certain cultures, several family members accompany the patient to a consultation; the consultation and the treatment plans are public activities. Thus, confidentiality may have completely different meanings. In some cultures, occasionally, patients may be treated without their consent (for example, by adding medication to their food or drink without their knowledge). In other cultures, such an approach would be totally unacceptable, and treatment without permission and consent may be seen as assault; but the IMGs may not be aware of this, which would create potential problems in patient care and professionalism.
As discussed above, IMGs may experience changes in self-esteem (20) related to aspiration/achievement disparity, as well as higher chances of failure in dealing with the academic stresses in the new country (18). Therefore, changes in lifestyle; the loss of self-esteem and country; and the lack of accessibility to family, friends, and social support may become demoralizing for IMGs when coping with academic and clinical as well as administrative pressures. Specific stages of the family life-cycle can exert additional stresses for IMGs and their families (21). Cultural bereavement (a sense of grief after the multiple losses involved when leaving one’s own culture, related to having migrated) may further contribute to compounding a sense of loss and lead to low self-esteem. Personal factors such as marital status, accompanying children, gender, and sexual orientation all play a role in the way an individual adjusts to a new culture. Expectations of those left behind will also add to pressures on individuals and their families.
Often, IMGs do not get placements in the specialty of their choice or in their preferred geographic setting. In countries such as Canada and Australia, IMGs often are appointed to posts that are difficult to fill. They may struggle with the new specialty, especially in assessments and examinations, thereby impeding their career progression.
After completion of training, whether to return to their own country or not will be another significant decision to face, and may well produce stress. At this point, personal and professional circumstances may well clash. Having been trained in one healthcare system, where they may have access to other professionals and investigation facilities, they may be reluctant to move back to a different system, which may also have changed further in their absence. This may conflict with personal reasons where their family (especially children) may feel settled in the new environs and may not wish to move again. The spouse’s career and children’s education will all have an impact on this decision-making process.
The personality of the individual and the type of society that the IMG is migrating from and to will play a role in a complex interaction and affect the ultimate adjustment. For instance, a socio-centric (collectivist) student from a socio-centric society such as India who migrates to an ego-centric (individualistic) society such as the U.S. or the U.K. may face completely different issues from an ego-centric individual migrating to these countries. Hofstede (22) describes five dimensions of culture, of which perhaps the most studied and significant is the collectivist–individualistic dimension. In a collectivist or socio-centric society, the individual’s identity is based on and is part of kinship; the emphasis is on “we-ness,” and is related to the role that individuals play. People from birth onward are integrated into strong, cohesive in-groups, which, throughout their lifetime, continue to protect them in exchange for unquestioning loyalty. This is not to say that all individuals in a socio-centric society will be socio-centric, but it is worth remembering these characteristics. Ego-centric societies are those where the ties between individuals are loose, and everyone is expected to look after himself or herself and their immediate family. These individuals believe in “I-ness”—individual autonomy, emotional independence, individual initiative, right to privacy, pleasure-seeking, financial security, and need for specific friendship. It has been noted that individualism is related to high levels of Gross National Product, but these societies also have high levels of crime, divorce, suicide, emotional stress, and mental illness. Ego-centric individuals in individualistic cultures will disregard the needs of communities, families, or workgroups, and socio-centric individuals will feel concerned about their communities and in-groups. Ego-centric individuals in collectivist societies will yield to group norms less than socio-centric persons in individualistic cultures. Hofstede (22) also argues that people from individualistic cultures are good at entering and leaving new social groups. Thus, in understanding any experience of migration, these dimensions must be taken into account.
In a cross-sectional survey study comparing IMGs and USMGs at six internal medicine (IM) community-based residency programs in Baltimore, Maryland, Gozu et al. (23) found that IMGs have lower fatigue, higher self-esteem, and greater personal growth scores. This needs to be explored further, particularly in relation to the socio-centric or ego-centric nature of individuals participating in the study. Bhugra et al. (24) found that rates of burn-out among doctors in north India were lower because they had better control of their working conditions. It is possible that something similar may be occurring in the Gozu et al. (23) data, where IMGs may feel higher self-esteem and also feel more in-control. It may also reflect the idea that migrants may be psychologically healthier, as they have had to “jump a phenomenon that has been interestingly called “migrant vigor.” This feeling may well play a significant role in better and perhaps quicker adjustment.
How IMGs are supervised is another factor to consider. Local supervisors may be unaware of an IMG’s cultural background and may criticize IMGs unduly, thereby adding to stress. Local employers may see and treat IMGs as second-rate employees filling unpopular posts in less sought-after specialties and geographical locations.
It is evident that if IMGs are not feeling “adjusted” and do not feel a part of the healthcare system, their personal and professional lives will be affected and, consequently, healthcare delivery will be, as well.
Employers, and the profession itself, must devise strategies to support, mentor, and enable IMGs. There is anecdotal evidence in the U.K. that IMGs are disproportionately more likely to be reported to the General Medical Council (the professional regulator) for poor performance than are indigenous doctors, but this needs to be explored further in a systematic manner across a number of settings and countries. Various strategies, such as periods of induction or orientation, education, coaching, or mentoring, and ongoing support can help IMGs manage to deal with stress and adjust in a healthy manner. Atri et al. (25) recommend that residency training programs should incorporate measures that would help boost the social support and acculturation experiences of IMGs. These may include training them in the local languages, the country’s history, culture, customs, and traditions, mental health legislation, and so on. As Atri et al. (25) found, acculturation and social support were key predictors of mental health. Hence, interventions that help improve the social support and acculturation of IMGs could potentially influence academic performance in a positive way.
Organizing support groups, international meals with various country cuisines, cultural retreats, and ongoing reflection on treatment of IMGs all demonstrate an appreciation of cultural diversity and contribute to a healthier and culturally rich learning environment for all involved in residency education (21). Knoff et al. (26) and Arthur et al. (27) describe the development of such a cultural and language program to meet the special needs of foreign psychiatric residents in the U.S. that benefitted not only the residents but also their families and, eventually, the residency program itself.
Some IMGs may get very little time to adjust to the new training environment, whereas others may have more flexibility in adjusting to the new culture. The trainees may have to start to grasp the subject-matter quickly while trying to adjust to the sudden change in their lifestyle. Faculty members and employers alike need to be made aware of the issues that IMGs may face in the course of their training, especially in the early days. The faculty needs to understand that international medical graduates are heterogeneous and culturally diverse groups that bring multiple perspectives to different issues (21). Not surprisingly, clear communication is important in the integration of IMGs (28). It is also advisable for IMGs to spend some time in the intended country of migration before actually beginning their formal residency training and get involved in such activities as observerships, research, language training, and so forth.
Wang and Lohfeld (29) found that processes related to recertification, barriers to entry into training, and processes of loss, disorientation, and adaptation will influence the process of adjustment. Several authors (30–32) have highlighted the impact of culture and boundaries in the training of IMGs. Gender as a variable must not be ignored (33) in this context, as women IMGS have additional needs and may need support, a need that must be addressed. Bickel (33) notes that, for women, both personal and institutional “glass ceilings” may obstruct their professional development. Women IMGs will also have additional problems related to gender roles and gender role-expectations that may be in conflict with the new culture. The discrepancy between the program directors’ expectations of a trainee’s performance and IMG trainees’ expectations of the training may further contribute to stress (34), and this difference in expectation needs to be dealt with. This may be carried out by educating the trainers as well as trainees, so that each side is very clear about what is expected from them and, if needed, where they can seek help. Similarly, IMGs from LGBT (lesbian/gay/bisexual/transgender) groups may have additional pressures that must be acknowledged, and these trainees must be supported and mentored according to their needs.
IMGs provide an extremely valuable source of healthcare delivery in many parts of the world. Their experiences before as well as after migration tend to vary tremendously. The factors discussed above are often ignored, but, for trainers, in particular, it is critical that employers and program directors are aware of the factors that will affect the functioning of the IMGs. By putting strategies in place to support, educate, and mentor IMGs, there is no doubt that subsequent functioning can be improved. Further exploratory work is needed as a matter of urgency to explore cultural factors and coping management across different countries. Thus, both systemic and individual factors need to be explored further in future studies.