Introduction

For migrant physicians (MP) with a medical degree from abroad who want to enter the medical labour market in their new country as practising physicians, different routes and interventions have been developed [1,2,3,4,5,6,7,8]. Empirical investigations on MPs often focus on their arrival and the early stages of recertification processes [1, 9], on educational interventions [1, 10] or on challenges, barriers and facilitating factors for workplace integration, i.e. when MPs have found employment [1, 9,10,11,12,13,14].

Less research exists on the process between an educational intervention and/or recertification and employment, although available findings indicate that MPs struggle to find employment [8, 15]. One barrier to entering the labour market for migrants is discrimination [8, 16,17,18,19,20], especially for those from non-western countries [17,18,19,20]. Highly skilled migrants are no exception [19, 21]. Some have experienced being undervalued at work despite their education [22]. This might also occur during the job-seeking process (cf. [23]), yet this issue has not been thoroughly explored. Other barriers to employment include a lack of knowledge about how to apply for work or how to act in a job interview, as well as language problems [19]. Also, as the recertification process takes time, many MPs are often older than peers educated in the new country [8, 19], and they might have families which can make it more difficult to study (cf. [8]). Empirical evidence also suggests that having children is a barrier as it reduces possibilities to move [19] to for example rural and remote areas where the absence of physicians are common, and MPs seem to prefer to live and work in urban areas [1, 24,25,26].

In Sweden, MPs trained outside the EU/EEA, as well as physicians trained in Sweden, have to apply for and complete a mandatory medical internship (MMI) and must pass an assessment before they can obtain a Swedish licence to practise. The number of MMI positions is, however, limited, which in turn results in longer waiting times [27]. Governmental reports suggest that MPs take longer than their Swedish-educated peers to obtain their Swedish licence to practise [28]. This may be because MPs lack the networks that might be needed to secure an MMI position [28].

From a societal and individual perspective, it is crucial that non-EU medical educated MPs’ competences can be put to use in the labour market without any unnecessary delay. To optimise and accelerate MPs’ entry into the Swedish healthcare system, there is an urgent need to explore how MPs currently enter into and advance within the system. Thus, the aim of this study is twofold: (1) to explore how MPs enter into and advance within the medical labour market in Sweden and (2) to identify perceived barriers and facilitating aspects for entrance into and advancement within the Swedish medical labour market.

One way to explore how MPs becomes a part of the Swedish medical workforce and advance within the medical labour market is to employ the concepts of social field and symbolic capital developed by Bourdieu [29, 30]. Simply put, a social field can be defined as a limited system of relations between social positions (individuals) with shared interests. In this article, we will use the concept medical field. The medical field comprises different kinds of medical professionals, positions for whom are allocated based on negotiations about common interests, including characteristics of medical science, medical work or medical competence [31]. Different types of symbolic capital, which can be cultural, social or economic, position individuals hierarchically in a given field. When capital is recognised in a specific field, it becomes symbolic capital, which thereafter defines a person’s position and possibilities within that field. Having a recognised education and degree, as well as requisite skills and knowledge, can be understood as conferring symbolic capital (cultural). Symbolic capital (social) can also manifest as a valuable and useful network within a profession. To be counted as symbolic capital, however, such a network should potentially lead to a gain—for example, employment (cf. [32]). Blain et al. (2016) suggested that symbolic resources influence opportunities for MPs to work in a medical field [33]. Having social capital in the form of a useful social network may thus facilitate employment.

The medical field can be understood as transnational, as it extends beyond national borders, and physicians can practise their profession in different countries [34]. However, a smooth transition from one country’s medical field to that of another country cannot be guaranteed. In the process of migration, a professional’s capital has to be recognised in the new country’s specific medical field. Depending on where a medical degree is acquired, its accompanying cultural and social capital might not be valued equally. For example, when physicians with a medical degree from outside the EU/EEA want to enter the medical field in Sweden as independently practising physicians, their medical degrees must be formally acknowledged before they can acquire a Swedish medical licence. Thus, MPs’ symbolic capital can, based on jurisdiction, be seen as being devalued when transferred to a new country’s medical field (cf. [23]). Accordingly, MPs must have their capital recognised and create new capital, which can be termed migration-specific capital [35]. Migrants also actively develop a ‘mechanism of validation for their cultural capital’ in the bargaining process when trying to enter the field [35]. One validation route is the institutionalised Complementary Program for Physicians (CPP). Via the CPP, MPs are expected to develop the country-specific competence needed to obtain a Swedish medical licence to practise. In this new country, with its dominant culture, MPs must further develop their symbolic capital for it to be of any real value (cf. [35]). The cultural capital (e.g. education, skills and knowledge) developed in another country’s medical field might represent a barrier if it is valued less than that of the new country.

Methods

For our research, we applied a cross-sectional study design. A questionnaire was distributed to a sample of MPs in Sweden who possessed a medical degree from outside the EU/EEA or Switzerland.

Context

Physicians with a medical degree from outside the EU/EEA or Switzerland can follow three routes to obtaining a Swedish licence to practise: (1) take a proficiency test and pass a course in Swedish laws and regulations, after which they must find and complete 6 months of clinical training; (2) participate in the CPP for 10 months; and/or (3) participate in Swedish medical education.

Routes 1, 2 and 3 can be seen as one phase in the licencing process. Until June 2016, all three routes had to be followed by another, stand-alone, phase: the 18–21-month MMI, which is assessed by a test. After July 2016, the MMI are however only applicable to those beginning route 2 or 3 after July 2016.

Some MPs change routes. For example, an MP may begin route 2 (CPP) but then take the proficiency test (route 1) to accelerate the licencing process. Before the CPP and the MMI, and before obtaining the Swedish licence to practise, MPs (as well as physicians educated in Sweden) may work as junior doctors, which is a restricted position before being licenced.

Participants and sampling

Potential participants for this study included MPs with a medical degree from outside the EU/EEA or Switzerland who enrolled in the CPP (route 2) during the 2009–2017 admission years—in total, 498 MPs. Route 2 was selected due to access to demographic data. (Unfortunately, one was deceased) CPP/route 2 potential participants were identified via registry data provided by the universities giving the programme. The sampling strategy was non-probabilistic and had the potential to include the whole population of route 2 participants, giving them an equal opportunity to participate in the study so long as they had updated their contact details in the registry. In Fig. 1, a detailed sampling frame is presented.

Fig. 1
figure 1

Sampling frame

Full size image

Participation was voluntary, and written informed consent was obtained from the participants. All collected data were anonymised to maintain the integrity of the individual respondents, and the data were handled and stored in accordance with the tenets of the World Medical Association Declaration of Helsinki (2008). The Regional Ethical Review Board in Stockholm, Sweden, approved the study (2017/1717–31/5).

Data collection

A self-administered questionnaire was developed to fit our aim. The questionnaire was developed following a seven-step process outlined by Artino et al. [36], as presented in Table 1.

Table 1 Development of the questionnaire
Full size table

The final questionnaire comprised the following sections: participants’ backgrounds and previous experiences, entrance into the labour market, interventions and the MMI. The questionnaire was composed in Swedish and included open-ended questions without character limitations and close-ended questions with binary, nominal or ordinal response options. Depending on the participants’ responses, different follow-up questions were used. Hence, no respondent received the exact same set of questions. The questionnaire was distributed digitally and answered during February and March 2019. The sampling frame in Fig. 1 presents the process, the number of reminders and the number of potential and actual respondents.

Data analysis

The completed questionnaires were exported to Excel. Descriptive statistics, which formed the backbone of the statistical analysis, were conducted on categorical data, which were subsequently presented as frequencies and percentages. The responses to closed- and open-ended questions were analysed to complement the quantitative results and deepen knowledge on the topic (cf. [40,41,42]). Thematic content analysis was used in this process [43]. The responses were read through for familiarisation, and significant sentences and/or keywords were identified and noted; then, central concepts were deductively grouped into the identified preset themes of used strategies, experiences of discrimination and valuing of competence (Table 1) (cf. [44]). The text answers were also analysed inductively to identify other themes related to barriers and facilitative aspects in the respondents’ answers (cf. [42, 44]). The findings were iteratively discussed between the authors to enhance credibility. Quotations were translated into English and edited to increase readability and protect confidentiality, without sacrificing the content or its meanings.

Results

We present the results as follows: ‘Response and respondents’ demographics’, ‘How MPs enter into and advance within the medical labour market in Sweden’, ‘Experienced barriers’ and ‘Facilitating aspects’.

Response and respondents’ demographics

The questionnaire had a 57% response rate (n = 283) (Table 2). The internal non-response bias was less than 10% on each question. The number of respondents (n) varied since the physicians were at different stages in their careers, and thus, not every question was relevant for everyone. Comparing all the participants who had begun the CPP, the distribution was equal regarding gender, year of birth and frequency of obtained Swedish medical licences. The respondents had resided in Sweden for an average of 10.3 years at the time the questionnaire was administered (n = 274). Respondents’ demographics are presented in Table 3.

Table 2 Distribution of eligible respondents and respondents by gender, birth year and possession of medical licence
Full size table
Table 3 Distribution of respondents’ demographics
Full size table

Of the respondents, 61% had worked in Swedish healthcare previous to enrolling in the CPP, on average for 20 months. Most had worked as assistant nurses, but some also held jobs as medical assistants and care assistants. A few had worked as junior doctors (a restricted position available before being licenced) or administrators, and some had worked as nurses, interpreters, in research or teachers of related healthcare-related subjects. Also, some respondents had taken internships and/or had been auscultating. It was common to have held several different positions.

When answering the questionnaire, 88% of the respondents currently held a position as a physician but were in different stages of their careers, as they had also started the CPP in different years (Table 4).

Table 4 Distribution of respondents (n = 249) with a position as a physician by type of position
Full size table

Of the respondents, 12% (34, n = 283) did not hold a position as a physician in Sweden when answering the questionnaire, but some held other jobs in the healthcare field or worked as physicians outside of Sweden. A few were unemployed, on parental leave or travelling.

How MPs enter into and advance within the medical labour market in Sweden

Of the respondents who had applied for a position as a physician after the CPP (n = 265, 249 working as physicians, and 16 not working as physicians), 42% had applied for 1–5 positions, 9% for 6–10 positions, 8% for 11–20 positions and 8% for 21–50 positions. Five percent of the respondents had applied for 51 or more positions. Of the respondents, 29% stated that they did not need to apply for work. In Table 5, the different channels used by respondents to find their first job as a physician are presented.

Table 5 Distribution of respondents (n = 257) who received their first position as a physician after the CPP
Full size table

In most cases, the first job for the respondents (n = 263) after the CPP was as a junior doctor (88%, n = 232), while 3% (n = 9) worked as medical assistants. The ideal position after having completed route 1 or route 2 (the CPP) was, however, the MMI, which was the first position for 3% (n = 7) of the respondents. The average time to begin the MMI (waiting time) was 16 months (n = 179) and, in the largest urban area, 20.4 months (n = 29). One quarter (26%) of the 248 respondents who held a position as a physician (junior doctor, medical assistant or had an MMI) as their first position after the CPP got their first job offer during the CPP. One half of these respondents got their first job offer 0–3 months after completing the CPP (route 2) or route 1 (some had changed routes). After 4–6 months, 12% had received and accepted a job after having completed the CPP or route 1; for 7%, it took 7 months or more. For a few respondents, their first job was as an assistant nurse, but they had also held other jobs.

Experienced barriers

We found several barriers to entering and advancing within the medical field in Sweden (Table 6). The themes of having another ethnicity and/or religion or other belief, having a different name, insufficient language skills, having the wrong age and having the wrong gender are associated with discrimination in Sweden [45]. In total, 29% of the respondents perceived having been disfavoured based on grounds related to discrimination during their job-seeking processes. The distribution of their experiences was equal in terms of gender and total respondents (Table 2): 44 women (54%) and 38 men (46%). However, there were some gender differences with respect to different grounds for discrimination, as displayed in Table 6. The answers showed that perceptions of having been disfavoured were related to several factors—for example, ethnicity, religion and gender.

Table 6 Barriers to and facilitating aspects and strategies for entry into and advancement within the medical labour market in Sweden
Full size table

Experienced barriers also included having one’s competence undervalued during the job-seeking process, which some respondents associated with originating from another country and/or having a medical degree from abroad, insufficient language skills and lacking work experience and work references from Sweden. In some comments, perceptions of having been disfavoured and having competences undervalued both occurred. For example, one respondent applying for the MMI stated:

Very little chance of succeeding despite letters of recommendation [ … ] and good references since I have worked in psychiatry, which is not so much merit for [MMI] and you do not give so much importance to my placements in the home country. Discrimination against foreign doctors and questioning the competences you have on your CV does not help either. One needs to show competence and become overloaded in practice before the employer trusts a foreign doctor, unfortunately. Therefore, foreign workers are most often employed in places where there are major staff shortages.

Of the 16 respondents who had grown up in Sweden or partly resided in Sweden, only two perceived having experiences that could be linked to discrimination, and only one had experienced having their competence undervalued, and the respondents perceived reasons for this were lack of work experience in Swedish healthcare and having been educated abroad (6%, n = 16).

Facilitating aspects

Facilitating aspects and barriers corresponded to each other and are hence presented in the same table (Table 6). For example, lacking contacts was an identified barrier, whereas having contacts was an identified facilitating aspect. In the same table, we also present different strategies used by the MPs for increasing opportunities for employment.

Respondents also had suggestions on what changes would better facilitate entry into the medical labour market: less bureaucracy, living in less segregated areas in which there is a mix of Swedes and foreigners, Swedish language courses, an introduction course on Swedish culture and mentality, more internships, increased CPP and MMI positions, developing a section for MPs within the physicians’ union and employers being more willing to hire foreign physicians.

Discussion

We explored how MPs with a medical degree from outside EU/EEA after the CPP entered into and advanced within the medical labour market in Sweden as physicians, and we identified perceived barriers and facilitating aspects. We found that even when the MPs had increased their symbolic capital by having a medical education from one country and participating in the CPP in the new country, they still experienced barriers to entering and advancing within the Swedish medical field. These barriers were mainly due to having a medical degree from and/or originating from another country, and they could also be related to the grounds of discrimination and/or having one’s competence undervalued.

Respondents mainly found their first positions via spontaneous job applications, during their CPP internship or via personal contacts. Our results are somewhat in line with previous research showing that MPs are approached with job offers during internships [8]. Respondents’ first job was mainly as a junior doctor, even though the ideal position after the CPP was an MMI. Our results support the indication that it takes longer for MPs to obtain a Swedish medical licence [28]. For our respondents, the mean time to begin the MMI was 16.2 months in comparison to physicians with a medical degree from Sweden or elsewhere in the EU/EEA, who had a mean of 10.3 months of waiting time in 2017 [46]. The waiting time to begin the MMI in Sweden’s largest urban region was 20.4 months for our respondents; for physicians educated in Sweden or elsewhere in the EU/EEA, however, the waiting time was 18.6 months in 2017 [46]. These differences might be due to the difficulties MPs experience, which were explored in our study.

Our results show that the respondents perceived that employers during the job-seeking process undervalued their competence in contrast to that of physicians educated within the country. These results are also in line with research showing that even “where ‘foreign’ qualifications are formally recognized, employers invoke criteria such as the lack of local professional experience” [35]. MPs’ symbolic capital might be formally acknowledged, but in the medical field, it does not seem to attain full recognition. MPs might be perceived as lacking needed ‘national’ capital and perhaps meet national-based protectionism [35], i.e. not being ‘Swedish’ enough. Employers might not know about the CPP or they may mistrust foreign competences, consciously or unconsciously (cf. [35]), just as employers do not always discriminate intentionally [20]. Our results can also be compared to research showing that employed MPs perceive their educations to be undervalued by their peers [22].

Almost one third of the respondents perceived having been disfavoured by employers in their job-seeking process for reasons related to discrimination. Specific combinations, such as age and country of origin, or gender and religion/or other belief, might generate more difficult barriers [47]. Experiences of being disfavoured due to reasons related to discrimination (regulated by law) and/or having one’s competence undervalued (not regulated by law) seem to be intertwined in the creation of barriers to the medical field. Some reasons for not being offered a job might be difficult to grasp or report due to ambiguity. In this respect, other aspects may need to be considered: For instance, is one being discriminated against for not getting a job if that job requires sufficient language skills for patient safety reasons but the job candidate lacks those skills? Having insufficient language skills might be a reason for having one’s competence undervalued and is usually related to being of another ethnicity. In Sweden, ethnicity is considered as a ground for discrimination.

Based on the respondents’ experiences, our interpretation is that the medical field is segmented (cf. [23]) and that MPs as a group are hierarchically positioned lower in the Swedish medical field than physicians trained in the country. However, how they are individually and hierarchically positioned is a complex issue, since MPs are not a homogenous group. Country of origin, country of education or MPs’ beliefs might affect how they are treated in the job application process [17,18,19,20]. Also, age and gender may also exert an influence. For example, internationally educated female health professionals appear to struggle more so than men [15, 33]. Individual characteristics influence routes (cf. [33]), and barriers might hence depend on several biographical aspects (cf. [8]).

We found that MPs perceived some aspects as being more facilitative of entering the Swedish medical field and that they had also tried different strategies. Having previously experienced the Swedish healthcare system prior to enrolling in the CPP as an assistant nurse was, for example, perceived as a facilitating aspect, as it helped develop knowledge about the Swedish healthcare field as well as Swedish language skills; these skills can be seen as national-specific and hence “can be converted into ‘national capital’, to legitimize belonging” [35], which might make getting a job easier.

Work in Swedish healthcare previous to enrolling in the CPP and internships during the CPP also seemed to increase opportunities to find work in the future, as the respondents received Swedish work references and developed useful contacts. It was perceived by many respondents that having contacts made it easier to get a job. Having contacts that leads to work can be seen as social capital, which is in turn a form of symbolic capital. Our interpretation is that respondents developed social capital (as in contacts leading to jobs) either strategically or unconsciously in Sweden during work or internships previous to or during the CPP. However, it is also our interpretation that MPs’ possibilities for gaining social capital might be based on first demonstrating their competence in the Swedish healthcare/medical field by, for example, expressing knowledge about the Swedish healthcare system (cf. [35]); such aspects can be perceived as facilitating employment. Having a level of formal education equal to that of physicians educated in Sweden does not seem to be enough, as Salmonsson et al. suggested, because they also ‘need to show that they are able to manage Swedish cultural codes in the health context’ [23]. But we also found that some respondents found their first positions via other MPs participating in the CPP, and hence, CPP peers seemed to be transformed into social capital. Capital other than Swedish national-specific capital can thus be of importance for getting a job, as suggested by Blain et al. [33], who highlighted the support of international medical graduate peers and how both sharing one’s migrant status and medical profession are of importance. The CPP seemed to increase MPs’ networks and opportunities for finding employment, except for facilitating professional development with national-specific capital to fit the new country’s needs and requirements. Research regarding internationally graduated nurses shows that participation in a bridging programme and having a social network seem to be good predictors for securing employment [48], and our results indicate that this might hold true for MPs. Our results are also in line with research showing that MPs after recertification are employed as physicians to a large extent [8].

As our interpretation is that MPs with a medical degree from outside the EU/EEA are, as a group, located hierarchically lower in the Swedish medical field than physicians with a medical education from Sweden, this probably explains why many respondents mentioned struggling to get a job and using different strategies to enter the medical field. Some mentioned working uncomfortable hours, being on call at all times or taking jobs with a low salary in a speciality in which they preferred not to work. Others had moved. MPs also changed specialties or took jobs they were over-qualified for. Those experiencing many difficulties probably also used multiple strategies (cf. [33]). In studies of migrants, it has been shown that one’s name can be used by employers to sort job applications and that name changes can increase opportunities to be hired [20]. In fact, a few respondents in this study did just that, which unfortunately reflects submission to an oppressive norm. On the other hand, if it facilitates an MP’s entrance into the labour market on an individual level, then it is understandable why it would be used as a strategy.

We found that barriers and facilitating aspects were in many cases two sides of the proverbial same coin. In other words, if developing language skills is facilitative, then being unable to speak that language is a barrier. Insufficient language is moreover one of the most common barrier identified in research [8, 19]. We suggest that multiple forms of discrimination can coexist and that in such cases, the struggle to get a job is even harder. On the opposite side however, when MPs develop national-specific capital by, for example, developing language skills and increasing their knowledge about the Swedish healthcare field, then job opportunities considerably increase.

Methodological considerations

First, a limitation with this study was that it only included participants from route 2. However, it is likely that our findings are pertinent to route 1 participants as well. Second, the study was based on self-reported data only, which can be biased; that said, subjective experiences and perceptions offer a preliminary step towards illuminating and addressing barriers and facilitating aspects.

Implications for practice and future research

By exploring and identifying aspects that influence the transition to a new country’s medical field, interventions can be developed or refined, and policies can be informed. As employers may discriminate unintentionally, they might also undervalue the competence of MPs unconsciously. Therefore, it might be important to train employers to increase their awareness of their own behaviours and prejudices and to realise that even those with good intentions can create or reinforce barriers for MPs. At the societal and individual levels, it is important that MPs participating in bridging programmes find employment afterwards; otherwise, it is a waste of effort, competence and money. In addition, work is an important factor for integration and well-being. For these reasons, the transition between a bridging programme and employment should be as fast as possible.

To integrate language training and MMI in bridging programmes is a further recommendation for practice based on this study. More specified training in the job-seeking process may also be useful, i.e. when to apply, how to write an application and questions that might come up during a job interview. Our study further implies that language training, internship or auscultation opportunities would be useful as soon as possible upon arrival, thus even before bridging programmes.

Future studies could specifically explore route 1 participants with a large enough sample to make valid statistical comparisons regarding the selection of routes within groups of MPs. Also, a corresponding study in which physicians educated in Sweden are contrasted with MPs might elicit alternative perspectives and contribute to knowledge construction.

Conclusion

Having personal contacts in the medical field who can be used as social capital may increase job opportunities for MPs. An active development of a variety of contacts seems beneficial; this can be established during interventions, such as internships, and with spontaneous job requests or social networks. MPs have very limited opportunities to network in a new country’s medical field during their training; consequently, this study revealed that they are at a disadvantage when entering and advancing within the medical labour market. MPs experience a variety of barriers while attempting to enter and advance within the Swedish medical labour market, partially due to reasons related to discrimination. Many MPs perceived having their competences undervalued due to their origin or education abroad. It is our interpretation that for optimal entry into the labour market, it is vitally important for MPs to get a job or internship as soon as possible within the medical field in order to gain proficiency in field-specific contexts, improve their language skills and develop contacts with colleagues and future employers.