In response to the objective that explored the scope of publications on the experiences of FMGs, the articles in this review mainly describe research studies that were conducted in various HICs. A total of six studies had been conducted in Canada, one of which included a combination of Canadian and Swedish research; four in Australia; two each in the United Kingdom and Finland; then one study each from New Zealand, the United States of America, Ireland, Germany, Austria and the Netherlands. Publications reviewed within the search period included the earliest publication in 2004 and the most recent in 2016. Of particular interest was the absence of publications from Africa and South Africa.
In answer to the objective that set out to describe the types of challenges reported by FMGs, three themes were found to be common as indicated in Table 2. The frequency of these descriptions suggests some degree of consensus that firstly confirm that FMGs experience a degree of difficulty in new host countries and the literature also provided insight into factors that could assist in the adjustment of FMGs to their new work countries.
FMGs reported professional barriers, lack of country-specific knowledge and stress as the most common sources of barriers on entering host countries while personal and professional support and the personal characteristics were some of the factors reported that facilitated their adjustment to the host country.
Although there are differences in the size of FMG populations in various HICs, they do exhibit evidence of extensive reliance on the use of FMGs in their overall health care and dependence on human resources .
Studies revealed that FMGs experienced various barriers to registration, licensure and in navigation accessing correct information within the health system [18,19,20,21,22]. In some cases, these barriers resulted in an inability to work in their profession, while other FMGs found work in related fields .
In the context of policy regarding FMGs in Canada, Borgeault and Neiterman noted several barriers for internationally trained health professionals. These include poor information to prospective FMGs, a lack of transparency about how to register and difficulty in having the educational credentials of FMGs recognised .
In the German context, FMGs similarly criticised the registration process for being slow, confusing and bureaucratic. The application to register for a specific hospital position was also criticised as physicians felt that their future employer had lied to them about working conditions at the hospital .
Among the many barriers reported to accreditation and registration to work in Austria where the requirement for many FMGs to repeat their internship or even their whole education, which set them back several years. The training in Austria was particularly challenging as FMGs had to master a language, which further complicates the situation .
While the barriers to licensure, accreditation and registration predominated in literature from Anglophone countries including Canada, Australia, the United States of America, New Zealand and Ireland, it featured as an even more complex factor in the non-English-speaking countries such as Germany, Austria and the Netherlands.
The same issues are reported in Finland. One of the major concerns, especially among physicians trained outside the EU/EEA trying to enter the profession in Finland, was access to work in the health care sector made problematic by a difficult licencing process, lack of information, bureaucratic difficulties and what FMGs experience as unfair test requirements .
In a New Zealand study, FMGs noted a lack of information about the requirements to pass the exams . FMGs perceived an overall lack of information, a lack of information specific to the New Zealand health system and limited places from where to access information throughout the process of registration also in finding employment and integrating into the workforce .
FMGs in host countries also experienced barriers in the practice of their professional and clinical skills [22, 24,25,26,27,28,29]. They reportedly required teaching on how to interact within the health care system and opportunities to practise specific professional and clinical skills for effective practice in the new settings . In the German context, FMGs reported feeling as if they lacked certain clinical competencies which they considered as necessary for successful clinical interactions such as the necessary experience with treating certain diseases, for example, tuberculosis (TB) because certain diseases were not prevalent in their country of origin . FMGs reported similar problems in using certain diagnostic/therapeutic tools and expressed that they felt that they required competencies in Germany exceeding their level of specialisation.
FMGs in Germany indicated their ability to speak in German as a significant barrier as they struggled with various aspects of language, difficulty in understanding the general everyday language, understanding unfamiliar medical terminology and the use of colloquial terminology for various diseases and medical conditions .
Limited career progression
FMGs in the United States of America reported various barriers to professional opportunities, limitations in practice location, choice of work, field of speciality and opportunities for advancement within various fields. They, however, recognised the professional limitations as part of the trade-off upon accepting work in the United States of America . In this way, the FMGs to the United States of America, as opposed to FMGs from Ireland and the United Kingdom, viewed the barriers and limitations as part of the “transactional cost of living and working in the United States of America” and they still perceived their professional experiences in the United States of America as significantly greater than those in their home countries .
FMGs recruited to Ireland experienced a de-skilling process. This was especially noticeable, among doctors from non-European Union countries. They encountered limited training opportunities; stalled career progression within the Irish health system in a process described a “brain waste” . The Irish health system also relied more on services rendered by junior hospital doctors, and vacancies were often at the junior hospital doctor level. In this way, FMGs to Ireland missed out on formal postgraduate training schemes and were offered only limited opportunities for career progression .
Austrian FMGs similarly reported not being able to work in their chosen environment and experiences of potential not fully being realised. The inability to work in their chosen health profession often resulted in frustration for FMGs who felt an inability to continue in their professions their professional knowledge being undervalued .
Despite having satisfied the entry requirements, FMGs in the New Zealand context of many FMGs who struggled to find employment and to integrate into their employment role or even to find medical employment . FMGs to New Zealand reported significant delays between passing their exams and receiving a job offer. This meant that those who were unable to find work either had to move out of the country or were forced to considered work outside the medical profession.
Work environment and workplace discrimination
FMGs experienced both overt and subtle forms of workplace bias and discrimination which occurred at all levels of the workplace and in interaction with patients, colleagues and with their supervisors. They also noted less overt examples at institutional leadership level. Chen described workplace bias and discrimination as occurring at a systematic level .
In this way, FMGs, irrespective of the number of years in US practice, perceived themselves as being held to a different standard of practice than their US-trained counterparts .
FMGs describe challenges in the transition to the culture and practice of medicine in the United States of America and normative work-related procedures, such as interviewing for residency .
Although FMGs from countries in the Middle East reported being asked discriminatory questions during job interviews, religion and appearance were not reported as real barriers in most of the studies. In a study conducted in Germany, male doctors from the Middle East had reported considerable difficulty working with the medical team during the initial period of practice. These FMGs reported feeling being discriminated by doctors and nurses but their experiences improved with time and as mutual respect and trust developed within the team .
FMGs in Germany experienced rejection and discrimination which they frequently attributed to their status as being a “foreigner”. They reported difficulties in interpersonal interactions with patients, colleagues and superiors and felt badly treated by colleagues (including nurses) and patients .
Lack of country-specific knowledge
With reference to the lack of country-specific knowledge of FMGs, the findings revealed that their knowledge of the health system, clinical skills and disease profiles did have an impact on their ability to adjust into the health care environment of the new country. FMGs in the various countries displayed variability in the medical knowledge, clinical skills and professional attitudes due to the variability of their undergraduate training and the various processes taught at undergraduate level to integrate their knowledge and clinical reasoning [20, 23, 25, 31].
FMGs in many of the studies and countries reported a mismatch between the tasks assigned to them and their level of expertise. They reported a lack of knowledge regarding their roles in the context of medicine of the new country . FMGs across the majority of countries experienced that they were frequently placed and employed in positions of greatest medical need, but that these needs had been inadequately matched to their clinical expertise and their previous experiences in the country from where they had graduated [26, 27].
Areas of greatest medical need often have greater working challenges and are often understaffed as the local indigenous/native professionals of the host country also find these positions challenging and hence refrain from accepting positions to practise in these areas, e.g. in Ireland. FMGs are recruited to work in posts with working conditions unacceptable to Irish-trained doctors . These conditions may include areas that are very rural, often primary health care that offers limited services for the community, with a high burden of disease and very vulnerable populations [25,26,27].
FMGs in Australia reported professional isolation, faced with a heavy work load and expectations of a high level of medical care despite their often inadequate skills for rural practice, lack of access to specialists and having to move frequently for different training opportunities .
Research with FMGs identified various challenges both in their language proficiency and in the process of cultural transition. They reported cultural barriers and a lack of awareness of cultural norms in caring for patients from diverse cultures [20, 23, 25, 26, 30, 32, 33], and difficulty across linguistic barriers in professional and personal communication in interactions with patients and colleagues [13,14,15, 20, 21, 28, 29, 34]. Language and cultural barriers were more often reported where FMGs migrated to non-English speaking countries, such as to the Netherlands, where those without a good command of the Dutch language experienced significant language barriers .
FMGs to English-speaking countries also reported difficulties in knowledge of the English language but also with specific difficulties in understanding subtle aspects of language such as used in sarcasm and colloquialisms. They report missing out on non-verbal communication, non-verbal clues and missing out on facial expression and various uses of body language [18, 21, 28, 29, 33]. Participants in Chen et al.’s study reported similar difficulties of subtle aspects of language, such as use of colloquialisms, sarcasm and idioms .
Participants perceived a loss of autonomy as physicians in the United States of America, with its emphasis on shared decision-making, in contrast to experiences in their home countries. This loss of autonomy sometimes led to decreased confidence. Finally, respondents were unaccustomed to the system of checks and balances in US health care and physicians’ sensitivity to potential litigation .
In the Netherlands, FMGs expressed frustration with the written examination being administered in the Dutch language at Maastricht University. They thought that the examination should be preceded by training in Dutch medical terminology. Language problems were considered a significant barrier during and after, study. Bad experiences relating to language, have reportedly led to FMGs ultimate rejection of a medical position .
FMGs to Finland described the Finnish language as difficult to learn, language courses in short supply and or of poor quality. FMGs also perceived that the Finnish system had failed to support them in language training, and their lack of language skills prevented FMGs from entering the Finnish system .
Understanding patient-centred communication is a major challenge for FMGs in their integration in the Australian health system. This difficulty is often a major shift from the culture in the country of origin of the FMG. While FMGs traditionally study in systems with a paternalistic doctor-dominated communication system, they experienced this very different to the Australia setting where the more educated and informed consumers demanded higher levels of information and discussion .
Organisational support, such as professional and cultural mentoring, were commonly identified needs of FMGs in Australia. Relationships were strengthened when staff and FMGs met socially and discussed cross-cultural issues, thereby establishing effective relationships within the Indigenous community .
Studies showed that FMGs to the majority of the countries represented in this review experienced professional and personal stress due to lack of personal and professional support [20,21,22,23,24, 26, 28, 29, 34]. Stress presented in the forms of workplace discrimination and bias at various levels of interaction with patients, nurses and colleagues [18,19,20, 25, 30], lack of choice regarding working hours, type of work, career opportunities and career progression . They also faced constant incidences of career uncertainty [21, 23, 33], felt held to different standards in the practice environments from their locally trained counterparts and needed more time to transition into new roles [18, 19, 21,22,23,24,25,26, 28,29,30, 33, 34].
A particular study from Finland had reported that FMGs faced a high risk of burnout and poorer work ability due to increased stress which ultimately resulted in FMGs having lower occupational well-being as compared with their locally trained counterparts .
Support: professional and personal
In response to the objective that explored the factors that were reportedly useful for FMGS to adjust to the new settings; the most comprehensive reports suggest for effective and comprehensive orientation. This was deemed essential to facilitate the acquisition of knowledge and to adjust to a new working environment [4, 7, 10, 12, 13, 22, 33, 34], as well as facilitating the sociocultural connection within the community which was identified as an important factor in fostering integration [22, 26, 28, 29, 32, 33].
The orientation sessions reported were either offered in the form of an induction or a bridging programme . Support from faculty mentors and peers greatly facilitated the acculturation process for FMGs . Both personal and professional support to FMGs along the journey and the use of mentoring were reported strategies that facilitated adjustment [18, 22, 24,25,26, 28, 29, 32, 33]. Han and Humphreys’ study in Australia showed that professional support from professional organisations and agencies combined with support from colleagues and supervisors, contributed significantly to increased professional satisfaction in a rural setting .
Information about banking, housing, schooling and recreational opportunities was identified as an important need for new IMGs. Support for the spouses of FMGs was also noted as an important component of orientation. Facilitating sociocultural connection within the community and with others from the same cultural background was also identified as an important factor in fostering integration into community and place .
Family support, hospital provided accommodation and administrative assistance from recruitment agencies were helpful to FMGs to settle into a new country and facilitated the adjustment process [26, 33].
Communication and language support were also a significant factor in the adjustment process of FMG resocialisation [18, 32,33,34]. The first few months following the point of entry into a medical position are a crucial time for the majority of FMGs in experiencing difficulties with communication. The importance of speech and language skills and the serious implications thereof for clinical practice of FMGs were reported across English-speaking and non-English-speaking countries [18, 32,33,34]. There is a great need to contextualise the learning of language strategies with staff within existing frameworks commonly used to improve the communications skills . FMGs who had taken additional language courses were able to improve their communication with patients and colleagues [18, 32] and found that knowledge of indigenous languages and understanding of accents and different cultural norms had helped them with successful integration.
Facilitating factors also included personal characteristics and strategies that many FMGs have characteristics including persistence, flexibility knowledge and experience gained from their country of origin. These had helped them to be successful in the host country in spite of multiple problems [18, 32]. FMGs also used various strategies to integrate and feel a sense of belonging in the host country. These included emphasising the similarities that they share with locally trained doctors or using their professional status as internationally trained medical graduates . Some of the FMGs have had to adjust their professional image to fit into the health system and many do this by minimising the differences between professional practice in the host country versus their country of origin or by asserting the superiority of the professional approaches acquired in their countries of origin . Other strategies like maintaining an optimistic attitude, reframing their experiences in a more positive light and trying to blend in helped the FMGs to integrate and adapt to the host country .
FMGs also felt positively about their unique skills and advantages that they brought to the host country. Many viewed aspects of their prior training and clinical practice as professional assets, identifying skills and advantages gained through experience in another health care system and sociocultural context. Many FMGs felt that theiroutsider status allowed them to better empathise with patients from ethnic/racial minority groups .