Foreign-trained Physicians Research Articles

Turnover intention of foreign trained physicians in German rehabilitation facilities—a quantitative study

BackgroundGermany’s medical specialist shortage is an acute challenge, especially in the rehabilitation segment. One countermeasure is to recruit foreign trained physicians (FTP), but the high turnover of FTP is a burden on the departments that train them and integrate them professionally. Preliminary research showed that currently one in three physician positions in German Pension Insurance (DRV) contract facilities is filled by FTP.This paper examines factors related to turnover intention of FTP in German rehabilitative departments.MethodologyIn spring 2022, we surveyed FTP across all inpatient and outpatient rehabilitation departments under the German Pension Insurance, using a two-stage cross-sectional approach. We conducted an online survey of FTP and developed a specialized questionnaire that captured sociodemographic, occupation related and professional biographical data, turnover intention, satisfaction, difficulties with professional integration and departmental structural characteristics. To analyze retention within the rehabilitation field, we used a measure of turnover intention, taking into account the direction of potential turnover, residency requirements and considerations of returning to the rehabilitation field. The data was evaluated in a subgroup analysis comparing FTP with and without turnover intention using Fisher’s exact tests.ResultsThe sample includes n = 145 FTP, 119 stating no turnover intention and 27 with turnover intention. More than half of FTP with turnover intention wished to move to an acute care hospital. FTP with turnover intention are comparatively younger and came to Germany and were employed in the rehabilitation departments more recently, indicating an earlier career stage. Besides, career-related and regional factors show the strongest relation to turnover intention.Discussion and conclusionThe results reveal a group of “established FTP” whose professional integration has been successfully completed. FTP with turnover intention are comparatively younger, career-oriented physicians for whom work in a rehabilitative facility is a career springboard to gain a foothold in acute care clinics. A limitation is that FTP with turnover intention are difficult to reach and may be underrepresented in our sample.

Turnover intention of foreign trained physicians in German rehabilitation facilities

Abstract Germany's medical specialist shortage is an acute challenge, especially in the rehabilitation segment. One countermeasure is to recruit foreign trained physicians (FTP), but high turnover of FTP is a burden on the departments that train them and integrate them professionally. Preliminary research showed that currently one in three physician positions in German Pension Insurance (DRV) contract facilities is filled by FTP. This paper examines the turnover intention of FTP in German rehabilitative departments. In spring 2022, we conducted an online survey of FTP that captured sociodemographic and professional biographical data, turnover intention, satisfaction, difficulties with professional integration and structural characteristics. The data was evaluated in a subgroup analysis using chi-square tests. The sample includes n = 145 FTP, 119 stating no turnover intention and 27 with turnover intention. More than half of FTP with turnover intention wished to move to an acute care hospital. They are significantly (p < 0.05) younger, have worked in Germany and in the institutions for a shorter time, and have studied in more countries than FTP without turnover intention. The latter are proportionally more likely to have a German specialist title and management responsibilities. FTP with turnover intention are far less satisfied, particularly with career prospects and institution location. Structurally, FTP with turnover intention are proportionately more likely to be based in peripheral regions than conurbations, which are where all FTP without turnover intention are based. FTP with turnover intention have reported a much higher rate of discrimination by non-physician colleagues. Key messages • The results reveal a group of ‘established FTP’ whose professional integration has been successfully completed. • FTP with turnover intention are comparatively younger, career-oriented physicians for whom work in the rehabilitation facility is a career springboard to gain a foothold in acute care clinics.

Physician workforce planning in Canada: the importance of accounting for population aging and changing physician hours of work.

KEY POINTS Canada has long struggled to maintain an appropriately sized physician workforce.[1][1]–[4][2] The recruitment of foreign-trained physicians over recent decades and, starting in the mid-2000s, increased domestic enrollments in medical schools has led to Canada currently having an

Foreign Practices: Immigrant Doctors and the History of Canadian Medicare. Sasha Mullally and David Wright

In Foreign Practices: Immigrant Doctors and the History of Canadian Medicare, Canadian historians of health Sasha Mullally and David Wright examine the interconnected history of Canadian healthcare and immigration. In documenting the relationship between the healthcare system and foreign-born and trained medical practitioners, Mullally and Wright demonstrate the profound impact that these physicians had on the success of Medicare and, in turn, on the shaping of Canadian identity in the mid-twentieth century. This text fills a significant gap in the historiography; the authors note that the social history perspective has long been lacking and the history of this multifaceted relationship has been dominated instead by policy histories, resulting in the absence of health care providers’ voices. This is remedied in Foreign Practices through both a micro and macro analysis, as chapter by chapter the authors first narrow the lens using existing and newly collected oral histories, published memoirs, and obituaries, and then broaden it using institutionally created sources such as published journals and the records of government offices. Through this methodology, the authors not only examine the relationship between Canadian institutions and foreign-trained physicians but also contribute to a growing pool of transnational histories studying the ways immigration policies were shaped across the global north and how immigrant physicians have in turn shaped the healthcare systems in their new home countries. While approaching this topic from the national and global perspectives, the authors skillfully negotiate the nuances that have shaped regional identity as they explore the motivations of immigrant physicians to settle or migrate within Canada after their arrival.

Facilitating the Path to Licensure and Practice: International Medical Graduates in Canada

ABSTRACT Canada relies heavily on foreign-trained physicians. As a Federation, with health care being a Provincial jurisdiction, this often translates into varied processes that international medical graduates (IMGs) must undertake to obtain a Canadian medical license. Two decades ago, several government officials and representatives of many physician organizations, including regulatory bodies, met and proposed 6 recommendations to make the processes standardized, simpler, and more transparent to aid internationally trained physicians in their pursuit of Canadian medical licenses. The Medical Council of Canada (MCC) was one of the organizations at the 2002 meeting in Calgary, Alberta. As an organization responsible for the assessment of physicians’ knowledge and skills and the issuant of the Licentiate of the MCC (LMCC), a prerequisite for Canadian medical license, the MCC was one of the institutions tasked with implementation of the recommendations. The purpose of this manuscript is to evaluate how well the recommendations were met. To do this, we explored whether the IMGs’ journey to obtain Canadian medical licenses in 2022 is more challenging or less challenging than in 2002. The MCC’s role in helping to effect changes in the licensing process was highlighted.

Foreign-Trained Physicians in the United States: A Descriptive Profile.

More than a quarter of physicians in the United States are international medical graduates (IMGs). This statistic, although large, does not fully capture the importance of IMGs in certain specialties and locations. We provide a comprehensive profile of IMGs documenting where and in what specialties they work and how these distributions have changed over time. Estimates show that IMGs disproportionately work in densely populated, low-income communities with sicker residents and low physician density. IMGs are overrepresented in primary care and the lowest paying specialties, and their concentration in these specialties is growing. Calculations show that U.S. medical graduates exit the workforce at 2.5 times the exit rate of IMGs suggesting that in the near future IMGs will likely provide care for an increasingly larger share of Americans.

The American Board of Radiology's Alternate Pathway for Diagnostic Radiology: What the Programs and the Applicants Need to Know

The American Board of Radiology (ABR) developed the international medical graduate alternate pathway to give foreign trained radiologists an alternate route to independent radiology practice without having to undergo radiology residency in the United States. After 4 years of fellowship/faculty experience in the same training institution, the foreign trained radiologist becomes eligible to sit for the radiology board examinations conducted by the ABR. As this pathway is not offered at every radiology training program, many training institutions are unfamiliar with the fundamentals of this pathway. At the same time, both the training institutions and the applying foreign-trained physicians face a plethora of confusing choices on the state and federal level. In this paper, we review the main factors which both the international medical graduate radiologists and training programs must consider before embarking on the diagnostic radiology ABR Alternate Pathway, namely, eligibility, visa options, state medical licensure requirements, their costs and implications for future employment opportunities.

When Refugees Care for Refugees in Lebanon: Providing Contextually Appropriate Care from the Ground Up

Despite a surge in initiatives to integrate foreign-trained physicians into local health systems and a drive to learn from localised humanitarian initiatives under the COVID-19 pandemic, we still know little about the on-the-ground strategies developed by refugee doctors to meet the needs of refugee patients. In Lebanon, displaced Syrian health professionals have mounted informal, local responses to care for displaced Syrian patients. Drawing on ethnographic work shadowing these healthcare providers across their medical and non-medical activities, we explore how clinical encounters characterised by shared histories of displacement can inform humanitarian medicine. Our findings shed light on the creation of breathing spaces in crises. In particular, our study reveals how displaced healthcare workers cope with uncertainty, documents how displaced healthcare workers expand the category of ‘appropriate care’ to take into account the economic and safety challenges faced by patients, and locates the category of ‘informality’ within a complex landscape of myriad actors in Lebanon. This research article shows that refugee-to-refugee healthcare is not restricted to improvised clinical encounters between ‘frontliners’ and ‘victims of war’. Rather, it is proactively enacted from the ground up to foster appropriate care relationships in the midst of violent, repeated, and protracted disruptions to systems of care.

We Need More Doctors

As Covid-19 strains our healthcare system, it also highlights the growing problem of a physician shortage in the U.S. This article seeks to understand why we are failing to produce enough doctors to meet a growing demand, and to explore how we can combat this issue by increasing funding for residency programs and easing restrictions on foreign-trained physicians.

Migration of Croatian physicians in the global context

As the global health care workforce faces a shortage, several EU nations focus on employing foreign-trained physicians. So much so, that in some countries of the EU, the percentage of foreign-trained physicians has reached 30 % and the percentage of foreign-trained psychiatrists has risen to 40 %. After Croatia entered the EU, together with a significant number of other Croatian citizens, a great proportion of Croatian physicians emigrated. Currently, Croatia is among the three EU countries from which the most physicians emigrate. There are both economic and non-economic factors that are influence individuals’ choice to emigrate. Benefits of emigration for Croatian physicians are high satisfaction with life standard, income, professional development, and better work conditions. However, there are also clear psychological costs involved, which hinder both the emigrants and their families, and make building of a social network and integration into society difficult. These are: moving away from family members, friends and a familiar environment, mastering another language, finding work opportunities for partners, adjusting to life in another country under discrimination by colleagues, patients and the general public. Countries of immigration face challenges with foreign-trained physicians because of their native linguistic and cultural background. Language proficiency training and national familiarization programs can improve integration of immigrant physicians and their families. In recognition that national skill shortages can cause disbalance on a global level, the WHO calls on high-income countries to strive for self-sufficiency, through educating, retaining, and sustaining enough physicians to staff their own health care systems.

Disruptive Innovation and the Residency Match: The Time Is Now.

Disruptive Innovation and the Residency Match: The Time Is Now.

Medical professionalism of foreign-born and foreign-trained physicians under close scrutiny: A qualitative study with stakeholders in Germany.

Hospitals in Germany employ increasing numbers of foreign-born and foreign-trained (FB&FT) physicians. Studies have investigated how FB&FT physicians experience their professional integration into the German healthcare system, however, the perspectives of stakeholders working with and shaping the work experiences of FB&FT physicians in German hospitals have so far been neglected. This study explores relevant stakeholders’ opinions and attitudes towards FB&FT physicians—which likely influence how these physicians settle in—and how these opinions were formed. We conducted a qualitative interview study with 25 stakeholders working in hospitals or in health policy development. The interviews were analyzed within a constructivist research paradigm using methods derived from Grounded Theory (situational analysis as well as open, axial and selective coding). We found that stakeholders tended to focus on problems in FB&FT physicians’ work performance. Participants criticized FB&FT physicians’ work for deviating from presumably shared professional standards (skill or knowledge and behavioral standards). The professional standards invoked to justify problem-focused statements comprised the definition of an ideal behavior, attitude or ability and a tolerance range that was adapted in a dynamic process. Behavior falling outside the tolerance range was criticized as unacceptable, requiring action to prevent similar deviations in the future. Furthermore, we derived three strategies (minimization, homogenization and quality management) proposed by participants to manage deviations from assumed professional standards by FB&FT physicians. We critically reflect on the social processes of evaluation and problematization and question the legitimacy of professional standards invoked. We also discuss discriminatory tendencies visible in evaluative statements of some participants as well as in some of the strategies proposed. We suggest it will be key to develop and implement better support strategies for FB&FT physicians while also addressing problematic attitudes within the receiving system to further professional integration.

Is there a ‘pig cycle’ in the labour supply of doctors? How training and immigration policies respond to physician shortages

Many OECD countries are faced with the considerable challenge of a physician shortage. This paper investigates the strategies that OECD governments adopt and determines whether these policies effectively address these medical shortages. Due to the amount of time medical training requires, it takes longer for an expansion in medical school capacity to have an effect than the recruitment of foreign-trained physicians. Using data obtained from the OECD (2014) and Bhargava et al. (2011), we constructed a unique country-level panel dataset that includes annual data for 17 OECD countries on physician shortages, the number of medical school graduates and immigration and emigration rates from 1991 to 2004. By calculating panel fixed-effect estimates, we find that after a period of medical shortages, OECD governments produce more medical graduates in the long run but in the short term, they primarily recruit from abroad; however, at the same time, certain practising physicians choose to emigrate. Simulation results show the limits of recruiting only abroad in the long term but also highlight its appropriateness for the short term when there is a recurrent cycle of shortages/surpluses in the labour supply of physicians (pig cycle theory).

A Quantitative Observational Study of Physician Influence on Hospital Costs.

Physicians serve as the nexus of treatment decision-making in hospitalized patients; however, little empirical evidence describes the influence of individual physicians on hospital costs. In this study, we examine the extent to which hospital costs vary across physicians and physician characteristics. We used all-payer data from 2 states representing 15 237 physicians and 2.5 million hospital visits. Regression analysis and propensity score matching were used to understand the role of observable provider characteristics on hospital costs controlling for patient demographics, socioeconomic characteristics, clinical risk, and hospital characteristics. We used hierarchical models to estimate the amount of variation attributable to physicians. We found that the average cost of hospital inpatient stays registered to female physicians was consistently lower across all empirical specifications when compared with male physicians. We also found a negative association between physicians’ years of experience and the average costs. The average cost of hospital inpatient stays registered to foreign-trained physicians was lower than US-trained physicians. We observed sizable variation in average costs of hospital inpatient stays across medical specialties. In addition, we used hierarchical methods and estimated the amount of remaining variation attributable to physicians and found that it was nonnegligible (intraclass correlation coefficient [ICC]: 0.33 in the full sample). Historically, most physicians have been reimbursed separately from hospitals, and our study shows that physicians play a role in influencing hospital costs. Future policies and practices should acknowledge these important dependencies. This study lends further support for alignment of physician and hospital incentives to control costs and improve outcomes.

Difficulties experienced by migrant physicians working in German hospitals: a qualitative interview study

BackgroundWith Germany facing a shortage of doctors, hospitals have been increasingly recruiting physicians from abroad. Studies in other countries have shown that migrant physicians experience various difficulties in their work, which might impact the quality of patient care, physician job satisfaction, and, accordingly, retention. The experiences of migrant doctors in Germany have not been systematically studied so far and will likely differ from experiences migrant physicians make in other contexts. A thorough understanding of challenges faced by this group, however, is needed to develop adequate support structures—as required by the WHO Global Code of Practice on the International Recruitment of Health Personnel.MethodsA qualitative study was conducted to give an overview of the multifaceted difficulties migrant physicians might face in German hospitals. Twenty semi-structured interviews with foreign-born and foreign-trained physicians were conducted in German. Participants were recruited via the State Chambers of Physicians and snowballing based on a maximum variation sampling strategy varying purposefully by source country and medical specialty. The interviews were recorded, transcribed verbatim, and analysed using qualitative content analysis.ResultsParticipants described difficulties relating to healthcare institutions, own competencies, and interpersonal interactions. Participants experienced certain legal norms, the regulation of licensure and application for work, and the organization of the hospital environment as inadequate. Most struggled with their lack of setting-specific (language, cultural, clinical, and system) knowledge. Furthermore, behaviour of patients and co-workers was perceived as discriminating or inadequate for other reasons.ConclusionsThis is the first study to describe the broad range of issues migrant physicians experience in Germany. Based on this information, institutional actors should devise support structures to ensure quality of care, physician wellbeing, and retention. For example, training opportunities should be offered where needed to support acquisition of setting-specific knowledge. Discrimination experienced by participants calls for better diversity management as a leadership task in healthcare institutions. Misinformation practices in recruitment could be managed by a voluntary code of ethical conduct. Further research is necessary to identify strategies that adequately address diverging normative positions between migrant health personnel and their patients and colleagues.

An international survey of medical licensing requirements for immigrating physicians, focusing on communication evaluation.

ObjectivesTo identify current entry requirements set by international medical licensing bodies for immigrating physicians, focusing on postgraduate level communication skills, clinical and technical skill assessments. MethodsA standardised, author developed survey was administered to a selection of national, state and provincial licensing institutions across 6 continents. Representative institutions were selected from the most populated regions of each continent. Surveys were administered by email and telephone. The information was also searched by website review. Website information alone was used if no response was received by the targeted institution after 2 phone/2 email attempts. Statistical analysis of the non-parametric data was conducted using SPSS (v.21). ResultsThirty-seven licensing bodies were contacted from 30 countries; verifiable information was available for 29; twenty-six responded to the communication inquiry. Sixty five 65.4% (n=17) surveyed communication skills, 100% involved language proficiency testing; 11.5% tested other forms of communication skills. For clinical and technical skills, 86.2% (n=25) assessed candidates by credential review, 72.4% (n=21) required both credential review and exam and 62.1% (n=18) used country-specific examination. A mentorship period were required by 37.9% (n=11), ranging from 3 months to 1 year. Only 2 countries identified examinations for recertification. No technical/clinical skills nor communication skill evaluation (beyond language proficiency) are routinely assessed at the postgraduate level. ConclusionsInternational assessments of migrating physicians are heterogeneous. Communication skills, beyond language proficiency, are not routinely assessed in foreign trained physicians seeking entry. The majority of clinical and technical skills are assessed by credential review only. This study highlights the lack of standardisation of assessment internationally and the need for steps toward a global agreement on training schemes and summative assessment.

Primary care physician characteristics associated with cancer screening: a retrospective cohort study in Ontario, Canada.

Primary care physicians can serve as both facilitators and barriers to cancer screening, particularly for under-screened groups such as immigrant patients. The objective of this study was to inform physician-targeted interventions by identifying primary care physician characteristics associated with cancer screening for their eligible patients, for their eligible immigrant patients, and for foreign-trained physicians, for their eligible immigrant patients from the same world region. A population-based retrospective cohort study was performed, looking back 3 years from 31 December 2010. The study was performed in urban primary care practices in Ontario, Canada's largest province. A total of 6303 physicians serving 1,156,627 women eligible for breast cancer screening, 2,730,380 women eligible for cervical screening, and 2,260,569 patients eligible for colorectal screening participated. Appropriate breast screening was defined as at least one mammogram in the previous 2 years, appropriate cervical screening was defined as at least one Pap test in the previous 3 years, and appropriate colorectal screening as at least one fecal occult blood test in the previous 2 years or at least one colonoscopy or barium enema in the previous 10 years. Just fewer than 40% of physicians were female, and 26.1% were foreign trained. In multivariable analyses, physicians who attended medical schools in the Caribbean/Latin America, the Middle East/North Africa, South Asia, and Western Europe were less likely to screen their patients than Canadian graduates. South Asian-trained physicians were significantly less likely to screen South Asian women for cervical cancer than other foreign-trained physicians who were seeing region-congruent patients (adjusted odds ratio: 0.56 [95% confidence interval 0.32–0.98] versus physicians from the USA, Australia and New Zealand). South Asian patients were the most vulnerable to under-screening, and decreasing patient income quintile was consistently associated with lower likelihood of screening, although less so for immigrant patients. This study highlights certain physician characteristics that are associated with cancer screening for eligible patients, including immigrant patients, and that should be considered when designing physician-targeted interventions. We have also highlighted an ethnic community, South Asians, which requires particular attention, both among its patients and its primary care providers. Future research should further explore the reasons for these findings.

Restriction of ACGME Fellowships to Candidates Completing US and Canadian Accredited Residencies: Level of Support and Expected Consequences

The aim of this study was to determine the level of support for the proposal to restrict ACGME-accredited fellowships to candidates who completed residencies accredited by the ACGME or the Royal College of Physicians and Surgeons of Canada. Perceptions of foreign-trained international medical graduates during and after fellowships were also assessed. An e-mail survey was sent to the members of the organizations that represent academic chairpersons (the Society of Chairs of Academic Radiology Departments) and radiology residency and fellowship program directors (the Association of Program Directors in Radiology) and to the program directors of the largest American radiology subspecialty society (the American Society of Neuroradiology). Results were analyzed separately for each of the 3 societies interviewed and then as a composite report for all 3 societies. Approximately 60% of the respondents said that they have offered at least one fellowship or faculty position to foreign-trained applicants in the past 5 years. More than 70% of the respondents said that these doctors performed equally to or better than American-trained ones both clinically and academically. The majority of members of all 3 societies responding opposed enactment of the rule, with the American Society of Neuroradiology being the most disapproving. The main concerns of those supporting the new rule were the inhomogeneous and sometimes unknown levels of training of the foreign-trained doctors and the need to favor American graduates. Those opposed were mostly worried about diminishing the quality of fellowship candidates, programs being unable to fill their positions, and a decrease in academic-oriented people. Most respondents opposed the proposed rule. The majority were supportive of foreign-trained physicians continuing their training in the United States.

Stratification in the Medical profession: Non-Western Physicians in Norway

Previous studies of internal stratification in medicine suggest that non-White foreign-trained physicians fill the bottom level of the specialist hierarchy. However, in this study we use administrative registers for majority and non-Western physicians in Norway and find that non-Western physicians acquire spe-cialisation in the same volume as majority colleagues, are equally likely to enter several of the high prestige specialties and are not delayed in their careers. The equal distribution is discussed as a consequence of strong professional closure, bureaucratisation of hiring procedures and hospital organisation and governmental influence. Identified patterns, however, are not unequivocal. First, immigrant phys-icians have a significantly higher chance of becoming specialists compared to majority physicians. Second, foreign-educated non-Western physicians have a significantly lower likelihood of specialising in surgery fields. The exception from the overall equality may result from exclusionary practices previously identified in surgery, but it could also result from differences in motivation.

Brain Surgery in the Bush: Adapting Techniques and Technology to Fit the Developing World

The critical shortage of surgical services in many areas of the world has profound effects on local communities. Approximately 11% of global disease burden can be attributed to causes that are surgically treatable. Efforts have been made to recruit professionals from developed nations to compensate for the lack of such expertise. However, this practice has created a cycle of dependency on foreign-trained physicians and the medical tools they bring. Recognition of this problem calls for adaptation of a novel problem-solving approach. This article describes techniques and technology available in east Africa that have been adapted to allow basic and emergency neurosurgery to be performed in the absence of complex medical infrastructure and equipment. Commonplace items found in the local environment can be used to emulate more sophisticated instruments, and community-specific engineering programs can be developed to provide locally produced appropriate technology that promotes independence from Western sources. The local economy benefits from much-needed stimulation when these tools are created locally, and this allows for readily available replacement and repair. More studies are under way to identify problems and implement interventions that are realistic and appropriate for these populations.