Expatriate Doctors Research Articles

The cultural adjustment of self-initiated expatriate doctors working and living in Ireland

The cultural adjustment of self-initiated expatriate doctors working and living in Ireland

Determinants of cross-cultural adjustment among self-initiated expatriate medical doctors working in Ireland

PurposeThe last decade has seen a significant increase in self-initiated expatriation research across various cohorts; however, limited research exists on the self-initiated expatriation of medical doctors despite their high mobility rates. The purpose of this paper is to investigate the determinants of cross-cultural adjustment among self-initiated medical doctors working and living in a host culture.Design/methodology/approachA questionnaire was distributed to self-initiated expatriate (SIE) doctors working in Irish hospitals. In total, 193 valid responses were collected. Three linear regression analyses were conducted to explore factors influencing cross-cultural adjustment among SIE medical doctors, along with qualitative insight into their adjustment to working and living in Ireland.FindingsThis study found that age, marital status, cultural novelty, previous international work experience, length of time working in the host culture did not influence the cross-cultural adjustment of SIE doctors. However, gender, language ability and perceived fair treatment were found to influence their cross-cultural adjustment in the study. Specifically, female SIE doctors reported higher levels of general adjustment to that of SIE male doctors. SIE doctors' language ability was found to influence their work adjustment, and those who perceived unfair treatment in the host culture reported lower levels of general adjustment.Originality/valueThis paper contributes to the limited knowledge and understanding surrounding the self-initiated expatriation of medical doctors and their cross-cultural adjustment to the host hospital and host culture.

Language barriers in healthcare delivery

The relevance of language for quality healthcare delivery cannot be overemphasised. Within the framework of communication accommodation theory, this paper discusses language barriers in expatriate doctor–patient communication in three state-owned hospitals in Ghana, and the strategies employed by the medical personnel to bridge communication gaps. The study design is qualitative and the data were obtained through semi-structured interviews with 16 expatriate doctors, three nurses and three patients. Furthermore, observation of five patient–doctor interactions was undertaken and notes taken. Both datasets were then analysed using the qualitative conventional content analysis approach. The findings revealed that the expatriate doctors employed convergence strategies such as ad hoc interpreters, gestures, picture charts and electronic dictionaries to deal with language barriers. The study is expected to stimulate further research into innovative ways of dealing with language barriers in expatriate doctor–patient interactions.

Views of expatriate Pakistani doctors about quality of medical education in Pakistan

Introduction and objective: Road Survey to evaluate and analyze the views of Pakistani doctors working in various developed countries about the quality of undergraduate and postgraduate medical education they received in Pakistan and how well it prepared them for their role as senior physicians in a multicultural healthcare workforce in many countries and in terms of parity to the medical education in their current country of work.
 Methodology: A web-based survey consisting of twenty item questions with graded answer choices, was prepared by the authors to include a multidimensional comprehensive questionnaire to collect the views of the target participants. The survey was completed anonymously on a mobile device or a computer with internet access and took 5 to 10 minutes to complete.
 Results: The results of this qualitative survey indicate that there is generally a broad convergence of opinion regarding the quality of Pakistani medical education, with primary medical education, more consistently considered higher quality, amongst the Pakistani physicians currently working in UK, USA and Middle Eastern countries.
 Conclusion: Overall the Pakistani education seems to be of a satisfactory level, but cannot be considered to be superior to the counterpart education from these countries, based on this survey results. Areas such as research methodology appear to be particularly weak and there was a divergence of opinion regarding what the top priority should be to address within Pakistani medical education and training environment. Many of these physicians would like to work in Pakistan again, provided that the working conditions are favorable.

Human stickiness as a counterforce to brain drain: Purpose-driven behaviour among Tanzanian medical doctors and implications for policy

We explain why a group of Tanzanian medical doctors decided to stay in their home country despite a massive brain drain and pressure to migrate. We argue that purpose-driven behaviour among medical doctors serves as a counterforce to brain drain, fostering human stickiness in a developing country context. A sense of purpose provides a novel lens to understand voluntary non-migration of highly-skilled professionals under extreme conditions. Furthermore, incoming expatriate doctors build local capacity by sharing skills and expertise with Tanzanian doctors. This affects the medical doctors’ motives to migrate, further reducing brain drain. These individual-level decisions not to migrate find their application in policy. We advocate policies that support purpose-driven behaviour and generate long-term commitment to a location, while advancing short-term mobility for knowledge sharing. The policy initiatives are targeted at actors in the sending and receiving countries as well as in international organisations, covering concerted multi-layered policies to support family and community embeddedness, to facilitate the incoming of expatriate doctors and foreign exchange, and to cultivate benefits of circular migration. We argue that migration behaviour is more individually grounded and socio-emotionally constructed than what dominant economic-based explanations suggest.

Expatriate health professionals in the Saudi Arabia private sector

This study aimed to identify the differences in job satisfaction levels among expatriate health professionals (EHPs) working in the Saudi Arabian private sector, the stressors affecting their job satisfaction, and the influence of those stressors on their turnover intention. A cross-sectional design was guided by Herzberg's Theory. A convenience sample of 204 expatriate doctors, nurses, and pharmacists in Saudi Arabia were recruited from the private sector. Data were collected from four urban hospitals in regions having 74% of the bed capacity in the private sector. A four-part instrument measured dissatisfiers, job satisfaction, turnover intention, and cultural unrest. The results showed that EHPs have moderate job satisfaction. There was a difference in job satisfaction levels in terms of profession and nationality. Stressors influencing job satisfaction support Herzberg's theory. There was a significant positive correlation between dissatisfiers and job satisfaction. Cultural unrest had a very weak positive correlation with job satisfaction. Working conditions, salary, supervision, interpersonal relationships, hospital policy and administration, and job security were significant predictors of job satisfaction. Job satisfaction and turnover intention have insignificant relationship. The private health organisations can use the findings of this study to promote job satisfaction, decrease turnover intention, and improve cultural acclimatisation

Expatriate doctors, medical litigations, and overall patient care: Taif study

Objective: In Saudi Arabia expatriates physicians involved in malpractice litigation process (MLP) risk travel ban, creating immeasurable stress as these procedures are quite lengthy with no insurance company or employer support. A survey study conducted in the city of Taif aimed to demonstrate the outcome of ongoing MLP on overall patient care. Methods: Various grades doctors of both sexes, from different surgical and medical specialties in Ministry of Health Hospitals, Taif city, were surveyed, including mental, pediatric, King Faisal and King Abdul Aziz Specialist Hospitals. The study was conducted between January 25, and May 3, 2015. Saudi nationals and paramedics were excluded from the study. Multichoice questions with space for suggestions were distributed and collected manually. It is a qualitative and cross-section study. Results: A total of 277 responded to the survey, 127/277, (45.84%) were involved in MLP of whom 97/127 (76.4%) were banned from travel. While in Linkert's scale, 96/277 (34.65%) were satisfied with the role of insurance company, 114/127 (89.8%) had little or no support from their employer during MLP, and 218/277 (96.03%) agreed that overall patient medical care will have a negative impact due to the ongoing MLP (P < 0.05). Conclusion: We believe the ongoing MLP is a fertile ground for developing defensive medicine culture. A stress-free environment strategy governed by support and legal protection by employer and insurance company respectively is suggested.

Cost-effectiveness of extracorporeal shock wave lithotripsy in a poor resource setting: The Okada, Nigeria experience.

Background:The first extracorporeal shock wave lithotripsy (ESWL) used in Nigeria was at Igbinedion Hospital and Medical Research Centre (IHMRC), Okada in 1992 and it functioned for 6 consecutive years. The objectives of this study were to analyze the cost-effectiveness of the procedure and highlight the associated factors that led to its failure.Methods:A retrospective study of medical records and publications associated with the use of ESWL at IHMRC, Okada, for the period of 1992 to 1998. The study was conducted between January 2003 and November 2008. Unclassified authentic information relating to the use of ESWL and treatment of upper urinary tract stones was obtained from the IHMRC Okada and some government hospitals on hospital bills. Relevant documents in public domains related to the national and international wages and emoluments of medical workers and socioeconomic development of Nigeria within the time the ESWL functioned were studied.Result:A total of 32 patients were treated with 51 treatment sessions which is an average of nine patients per year and an average of two treatment sessions per patient were involved. The reasons for the low patronage were the extremely low stone formation rate of Nigerians, poverty, and out-of-pocket payment system. In addition, each treatment session of ESWL at Okada cost an average of $681.8 compared to $227.3 for open nephrolithotomy in a nearby high profile teaching hospital. The IHMRC, Okada, paid an average annual salary of ₦180,000 ($8,181.8) for each medical consultant compared to ₦120,000 ($5,454.5) paid by federal teaching hospitals in Nigeria within the period. Expatriate consultant doctors from Europe and USA who initially manned the lithotriptor at IHMRC, Okada, were paid much higher salaries. Average annual income of $5,909 for each of the 6 years amounting to a total of $34,771.7 for the six years was realized which could not maintain staff salaries in the hospital leading to staff emigration, decline of the hospital services, and eventual closure of the ESWL procedure center in the hospital in 1998.Conclusion:ESWL at Okada was not cost-effective both to patients and the hospital management. Despite these, ESWL is desirable in poor-resource countries because of its noninvasiveness, low morbidity, and usability in patients who are unfit for open surgery. Purchasing high technological medical equipment as commodities by sub-Saharan Africans without considering the prevalence of diseases they are meant to cater for, their maintenance for steady function during useful lifespan, their cost-effectiveness and how to recoup the money spent on investments depletes the scarce foreign exchange reserve of the home countries and is eventually counterproductive as exemplified by this case.

A test of the relationship between person–environment fit and cross-cultural adjustment among self-initiated expatriates

Understanding an expatriate's cross-cultural adjustment to the various aspects of their host environment and organization has been a focal point of research for several decades. Person–environment (PE) fit refers to the degree of fit an individual has with various dimensions of their host environment, and past research suggests that successful PE fit positively influences adjustment. However, the strength of these relationships remains under-researched. Drawing upon data gathered from 369 self-initiated expatriate doctors working in Ireland, we examine the strength of the relationship between PE fit and cross-cultural adjustment. Our results suggest that dimensions of PE fit influence cross-cultural adjustment to varying degrees. Thus, person–job needs-supplies fit was the only fit dimension to influence interaction adjustment, while person–job demands abilities influenced both work adjustment and, to a lesser extent, interaction adjustment. Person–organization fit influenced work adjustment, while person–supervisor fit had no relationship with adjustment. These findings have implications for organizations when recruiting and supporting self-initiated expatriates.

OC-028 Developing sustainable GI endoscopy training in Malawi

IntroductionSustainable endoscopy services could improve management of upper gastrointestinal malignancy and haemorrhage, both common in Malawi. Since 2008 we have committed to improving endoscopy training through an International Health Link...

Reflections on nursing ethics

My professional career started in a regional hospital in south-eastern Ethiopia where no nurse had set foot before. I had to take a bus part of the way and a truck to reach the town as the roads were impassable in rainy season. The hospital had two expatriate doctors and several health assistants. Part of my duty included supervision of the health assistants. The hospital had never admitted inpatients, and it was functioning as an outpatient facility. The beds and the surgical equipment were locked in the store room. With my recruitment, the hospital was expected to admit patients and perform minor surgery as one of the doctors was a surgeon. We set up a medical and a surgical ward and an operating theatre, which was a testing experience for a newly graduated nurse. In this uncharted territory, it is inevitable that ethical challenges and dilemmas would arise. My first dilemma occurred when I was asked to assist in medical assessment of prisoners for ‘fitness for flogging’ or corporal punishment – a court order that must be complied with. The perplexing questions for me were as follows: should a doctor certify a patient ‘fit for flogging’? Can a nurse assist in such a procedure aimed at causing pain and suffering? Can medical assessment humanise the inhuman and cruel act of torture? I had a feeling of ethical distress that I was involved – albeit in an assistive role – in a procedure intended to cause pain and suffering to people, contrary to the ethical tenets of nursing, which affirm alleviation of suffering as a primary nursing responsibility. My second ethical dilemma in those early days was related to what we now call ‘task-shifting’ – in which tasks normally performed by a physician are delegated, or shifted, to nurses and those performed by nurses to less qualified health-care assistants. In principle, task shifting improves access to care and is desirable. Yet my training did not prepare me for diagnostic and prescriptive tasks. But in the absence of physicians, I had often to function beyond my scope of practice, particularly during night and evening calls. While ‘delegation’ has been a historical part of nursing practice, the tasks were not delegated to me based on my competence but by default because of lack of physicians. To make matters worse, my education in nursing ethics was limited and lacking in decision making. I realise now that while nurses in other parts of the world were facing complex challenges related to life and death issues such as euthanasia and end-of-life decisions, my ethical distress was related to everyday issues, including whistle-blowing, scope of practice, staffing levels and access to care, that could have been addressed with proper training in ethics and ethical decision making. I could easily trace my interest in nursing ethics back to those early days when I faced ethical dilemmas with no support or reference materials. Several years later when I had the privilege to lead the ethics portfolio at the International Council of Nurses (ICN), the nurse in the front line is always on my mind. That is why during my visits to health facilities, I often ask nurses about the ethical challenges they face in their day-to-day practice. I often ponder whether we are providing nurses with adequate training in nursing ethics and with tools and frameworks to help them make ethical decisions.

Comparison of British and French expatriate doctors’ characteristics and motivations

ObjectiveThe aim of this study was to analyse the migration of doctors between the UK and France, in an attempt to identify the reasons for these migrations.DesignThis was a cross-sectional...

Medical responsibility in the United Arab Emirates

Medical responsibility in the United Arab Emirates was formerly defined and governed according to Law 7 of 1975 for the practice of medical professions, which had been a part of civil law. The passing of Law 10 of 2008, namely the “Law on Medical Responsibility in UAE”, enacted on 16th December 2008 created a new framework to deal with this issue. One of its provisions required medical practitioners to hold insurance policies, so that insurance companies pays damages to the plaintiff (patient) injured as a result of a physicians’ negligence. This paper outlines the issue of medical responsibility and medical negligence. The author’s translation of the new law into English is included so that its full text is available for the readers, especially expatriate doctors working in the UAE. Where appropriate, a brief comparison between the old law and new laws is also presented. The objective of this paper is to provide medical practitioners with basic information about the subject in general and to this legislation in particular. It is mandatory for doctors to realize inherent risks involved in the course of their practice. A basic knowledge of the law is required to avoid pitfalls and to safeguard oneself against errors arising from ignorance of the duties and rights of the professional person.

The impact of contracting out on health outcomes and use of health services in low and middle-income countries

Recent literature on the lack of efficiency and acceptability of publicly provided health services has led to an interest in the use of partnerships with the private sector to deliver public services. To assess the effectiveness of contracting out healthcare services in improving access to care in low and middle-income countries and, where possible, health outcomes. We searched a wide range of international databases, including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE, in addition to development studies and economic databases. We also searched the websites and online resources of numerous international agencies, organisations and universities to find relevant grey literature. The original searches were conducted between November 2005 and April 2006. An updated search in MEDLINE was carried out in May 2009. Contracting out health services is defined as the provision of healthcare services on behalf of the government by non-state providers. Studies had to include an objective measure of at least one of the following outcomes: health care utilisation, health expenditure, health outcomes or equity outcomes. Studies also needed to use one of the following study designs: randomised controlled trial, non-randomised controlled trial, interrupted time series analysis or controlled before and after study. We made an attempt to present results from the different studies in a systematic way, however due to the diversity of sources, contexts and methods used, we undertook a narrative synthesis. Three studies met our inclusion criteria (one after re-analysis of data). These studies suggest that contracting out services to non-state providers can increase access and utilisation of health services. One study found a reduction in out-of-pocket expenditures and improvement in some health outcomes. However, methodological weaknesses and particularities of the reported programme settings limit the strength and generalisability of their conclusions. Three studies suggest that contracting out may be an appropriate response to scale up service delivery in particular settings, such as post-conflict or fragile states. Evidence was not presented on whether this approach was more effective than making a similar investment in the public sector, as there was not an exact control available in any of the settings. In addition, the introduction of non-state providers into some settings and not others also brings many potentially confounding variables, such as the presence of additional management expertise or expatriate doctors, which may improve drug supply or increase utilisation.

A negative trend of biomedical research in Libya: a bibliometric study

It is well established that Libya is lagging behind its peers in biomedical research. The aim of this study is to analyse all the original biomedical publications affiliated with Libya from 1973 to 2007. PubMed and the Science Citation Index Expanded were searched for 'original research' biomedical studies affiliated with Libya. The generated data were hand searched and 329 'original research' studies were included in the analysis. The first study was published in 1973. Publication rate peaked to an average of 15.2 studies per year during 1986-1996 and dropped to an average of 8.8 studies per year during 1997-2007. Of 166 first authors; 41% were Libyans and 59% were expatriates. The latter contributed 104 studies between 1986 and 1996 and 36 studies between 1997 and 2007, while the Libyans contributed 63 and 61 studies in the two respective periods. Authors affiliated with Benghazi produced 67% of the published studies, while authors from Tripoli produced 30% and other medical schools, hospitals and research centres from other Libyan cities produced only 3%. This study showed a decline in biomedical research publication in Libya. We propose that the lack of a research culture among the Libyan medical professionals is one of the factors contributing to this decline, which coincided with the departure of expatriate doctors from Libya. Raising awareness of the importance of research and improving research skills among Libyan medical professionals may help to reverse the current trend.

Think Globally Act Locally: The Case for Symphysiotomy

When expatriate doctors from developed countries working in sub-Saharan Africa suggest to the local doctors and midwives that symphysiotomies should sometimes be done, they are silenced neither with quotations from the medical literature nor with tales of patients seen, but with: “If symphysiotomies are such good operations why don't you perform them at home?” Here is why.

Rebirth of the health-care system in Cambodia

Rebirth of the health-care system in Cambodia

Progress of surgical training in Papua New Guinea to the end of the 20th century.

Health care in Papua New Guinea (PNG) throughout the 20th century has been characterized by a significant shortage of medical practitioners and surgical expertise. A number of initiatives within the country and from outside have sought to address these deficiencies of numbers and quality. The present paper seeks to review the development of surgery and surgical training in PNG. Review of the surgical literature, reports and records in the Division of Surgery at the University of Papua New Guinea (UPNG), and personal observations are used to look critically at the content and productivity of the various training initiatives. For the first half of the century, PNG relied on national medical assistants who were trained, supervised and directed by expatriate doctors. Medical training of PNG doctors began in 1951 and by 1999 more than 600 doctors had graduated. Expatriate specialist surgeons arrived in 1950 and were the only surgeons until the postgraduate Master of Medicine (surgical) programme produced its first graduates in 1978. This programme has now produced 37 surgeons who are reasonably well distributed throughout the country. Higher surgical diplomas were introduced in 1994 for more specialized training of some of the general surgeons. These training developments have been supported by AusAid as well as by Australian surgeons. Surgical expertise has progressively improved throughout the 20th century with the most major advances being achieved in the last decade. Training programmes have provided an expanding core of expertise of considerable quality, but the numbers of doctors and surgeons remain well below requirements.

Teaching tropical medicine: a personal view in perspective

Over the last few decades, European courses in which ‘classical’ tropical medicine (i.e. parasitology, entomology and clinical aspects of tropical diseases) is taught have largely become anachronisms. Most countries in the tropics have their own medical schools and few have much need of expatriate doctors. There do, however, appear to be other ways in which Europeans may still help improve health in the tropics. One is to control the quality of the expatriate nurses who are still in demand in the tropics (often as cheaper, generally less demanding substitutes for doctors). This may be achieved by only training the best, insisting they spend some time after graduation gaining maturity before they leave for the tropics, ensuring they realise that their clinical skills will probably be inferior to their local counterparts in the tropics, and encouraging them to continue studying once abroad. The second way Europeans may help is to change the bias of their courses from teaching to training. There seems little doubt that the intellectual personalities of the brightest young men and women in the tropics often develop far better when they spend a period in a foreign environment, especially when they are allowed to function within a team, with trainees and trainers from other countries. Some ‘international’ courses may offer such benefits, especially if closely tailored to the needs of the trainees and their home countries.

Teaching tropical medicine: a personal view in perspective

Over the last few decades, European courses in which 'classical' tropical medicine (i.e. parasitology, entomology, and clinical aspects of tropical diseases) is taught have largely become anachronisms. Most countries in the tropics have their own medical schools and few have much need of expatriate doctors. There do, however, appear to be other ways in which Europeans may still help improve health in the tropics. One is to control the quality of the expatriate nurses who are still in demand in the tropics (often as cheaper, generally less demanding substitutes for doctors). This may be achieved by only training the best, insisting they spend some time after graduation gaining maturity before they leave for the tropics, ensuring they realise that their clinical skills will probably be inferior to their local counterparts in the tropics, and encouraging them to continue studying once abroad. The second way Europeans may help is to change the bias of their courses from teaching to training. There seems little doubt that the intellectual personalities of the brightest young men and women in the tropics often develop far better when they spend a period in a foreign environment, especially when they are allowed to function within a team, with trainees and trainers from other countries. Some 'international' courses may offer such benefits, especially if closely tailored to the needs of the trainees and their home countries.