Have medical degree, will travel

A recent piece by Freeland in the Financial Times spoke to the ‘non-nation generation’.1 She wrote about the adult children of globe-trotting executives who, having been raised in multiple countries, often shed their original national identities. These are the consequences of human movement in Friedman’s ‘flat’ world. More profound consequences of this phenomenon are seen in the ever increasing movement of physicians and nurses. This was highlighted around the time of the 2005 G8 summit.2 Furthermore, due to the out-migration of talented individuals from poorer regions of the world, certain commentators called for action on the part of the receiving nations.2,3 Yet there are critical issues that need to be considered on the other side of the migration equation. Is the movement primarily due to ‘pull’ factors in the developed world or might there be ‘push’ factors operating at home?3 Is the movement [of IMGs] primarily due to ‘pull’ factors in the developed world or might there be ‘push’ factors operating at home? Active recruitment of IMGs from the developing world …is no longer considered ethical…the situation from the IMG’s point of view is quite different. A focus on defining ‘normal’ expectations for the quality of medical education is a key starting point, as they can lead to the development of international standards. Better faculty preparation was a key recommendation of the Canadian IMG Task Force. The reasons behind physician migration and mal-distribution need study. Two articles in this issue of Medical Education deal with the migrant or ‘push’ side of the issue. They serve to remind us of the complexity of the migration question. Syed et al. addressed the etiology of the out-migration of final year medical students from the two largest of eight medical schools in Karachi.4 Wong and Lohfield analysed the experience of 12 international medical graduates (IMGs) as they moved through their postgraduate clinical experiences to become certified anew in Canada.5 Taking the papers in an educational sequence, that by Syed et al. addresses a dilemma throughout the developing world. Why do many of their graduates prefer to study or work elsewhere? Their questionnaires, unlike most other studies, focused on the local educational and working environments. For the two schools, 65% and 95% of graduating students indicated their intent to proceed abroad for postgraduate training. The primary reasons were poor quality of postgraduate training at home and the poor salary structure. Other issues cited in the open ended questions were poor working environments and lack of rigor in teaching residents in the domestic university hospitals. These responses are important because in the connected world of today, the educational practices in other countries are easily discovered. If their economic and social situations are favourable, many students have the choice of migrating for exactly these reasons. While the active recruitment of IMGs from the developing world to deal with local shortages abroad is no longer considered ethical, even a hostile act, the situation from the IMG’s point of view is quite different. I recall a young physician at a conference on the outward migration from the sub-Saharan area commenting that it is one thing not to recruit from their region, but it is unacceptable to bar their migration if they find themselves unprotected or attacked in their own countries! For example, to restrict IMGs’ employment because they were trained in poor countries, is unacceptable.2,3 So where to begin? Focusing on the educational issues, there have been attempts to improve the quality of international medical education. The former Institute for International Medical Education under the leadership of Roy Schwarz and the more recent fellowship programs of the Foundation for the Advancement of International Medical Education and Research (FAIMER) are to be lauded. A focus on defining ‘normal’ expectations for the quality of medical education is a key starting point, as they can lead to the development of international standards. But the creation of incentives for the medical schools is also needed. The intent of the World Federation of Medical Education in their recent discussions over the World Health Organization Directory of Medical Schools, and the promotion of similar standards by FAIMER for their International Medical Education Directory list of approved schools, may be key steps in the promotion of international accreditation for medical schools. These efforts also begin the promotion of ‘best’ educational practices in a positive manner. They, thus, can serve as incentives for medical schools, and not serve as punishment to individual IMGs for unknowingly having gone to an unaccredited school. Moving to the postgraduate side, using a phenomenological (qualitative) research approach, Wong and Lohfield looked at IMGs’ perceptions as they moved through their training experiences in the course of achieving certification anew in Canada. With the small numbers of interviewees, there was no attempt to study specific programs. Rather, the authors focused on emerging ‘themes’ that characterize the IMGs’ three-phase transition process. They identified loss, disorientation and adaptation as phases through which IMGs should pass to feel fully integrated into their new professional environment. While our current follow-up study of young physicians in Quebec found that the adaptation to clinical practice is an issue for both IMGs and local graduates, it presents a substantially greater challenge for IMGs. In addition, Wong and Lohfield’s findings are very compatible with interview and focus group findings that took place under the work of the Canadian Task Force on the Licensure of International Medical Graduates (IMG Task Force).6 All these findings should be useful to all local postgraduate training communities in preparing their faculty members for the role of training of IMGs. That is why better faculty preparation was a key recommendation of the Canadian IMG Task Force. The IMG’s adaptation challenges in Canada have led to faculty development programs regarding cultural norms,7 as well as the creation of learning programs to prepare IMGs for challenges related to wider health system issues operative in practice.8 Thus, Wong and Lohfield’s contributions add insights that faculty in any country should apply when dealing with recently arrived IMGs. Stepping back from education issues, better understanding of the whys behind the migration of all physicians is crucial.3,9 These phenomena are not restricted to IMGs and they silently fuel IMG recruitment. The massive movement of physicians within the Great Britain–USA–Canada–Australasia axis illustrates the underlying issues.10 In addition, the reasons behind physician migration and mal-distribution within geographically large countries like Canada, Australia and the USA need study, so that incentives are developed and less IMG ‘pull’ is needed to solve mal-distribution problems.3,9 Meanwhile, the calling cards of all medical graduates will continue to paraphrase the old-time western television series: ‘Have gun, will travel’! (998).

Fetched live from OpenAlex and de-inverted. Abstracts are not stored in this database: the inverted indexes are 8.6 GB of the frame’s 9.3 GB of text, and the host has 13 GB free.