Encountering the Familiar Unknown

Introduction

As a discipline, medicine has expanded by moving its practitioners, with their skills and knowledge, from one part of the world to another. Amidst this expansion, various actors, such as regulatory bodies, hospital administrators, and medical organizations, have devoted considerable effort towards creating a sense of uniformity about medical practice. This drive for cohesion stems from the proliferation of medical schools around the world, the migration of large numbers of health professionals, and an abundance of new technologies. The appeal for uniformity is embedded in protocols, core physician competencies in medical school curricula, and the push for randomized controlled trials. These developments attempt to privilege the concept of medical practice not only as a consistent and predictable science (Epstein 2007, 46) but also as easily transportable.

The push for medical universalism hides the social labor involved in moving medicine between various contexts of practice (Berg 1997, 169; Bowker and Star 1999, 292). All practitioners must undertake this work when they move between different medical settings, but it is particularly marked in the cases of those who cross culturally distinct borders. This article highlights this social labor based on an ethnographic study of traveling medical practitioners, usually known as international medical graduates, who must apply medical practices developed in one context to another. Many health care systems around the world, including in the United States, Canada, Australia, New Zealand, and the United Kingdom, rely on international medical graduates to address workforce shortages, and a growing number of doctors move between numerous countries.

Like all skilled migrants, these doctors encounter workplaces which are “familiar unknowns,” a phrase I borrow from Nigel Thrift (2004, 585) to describe both the hospitals where international medical graduates find themselves and the practices linked to these institutions. Thanks in large part to the push for universalism, many similarities exist between hospitals around the world. For instance, a hospital in Melbourne may look, smell, and sound like a hospital in Montréal. However, as various analysts have emphasized, the world of medicine is not homogeneous. Instead, it is filled with divergent cultural practices (Berg and Mol 1998; Bowker and Star 1999; Good and DelVecchio Good 1993; Maretzki 1989; McKinlay et al. 2006). Many of the international medical graduates in my study found these differences unsettling, and they learned that medical practices in their new settings were similar and unfamiliar to what they knew before entering those settings.

Despite the ongoing movement of skilled migrants globally, social scientists have neglected to study the work involved in moving practices between contexts which workers experience as both familiar and strange. In the medical context, sociologists and anthropologists have examined the medical profession (Atkinson 1995; Finkler, Hunter, and Iedema 2008; Fox 1992; Hahn 1985; Katz 1985; Millman 1976; Zetka 2003), hospital spaces such as mortuaries (Horsley 2008), pediatric wards (Hunter et al. 2008), corridors (Long, Iedema, and Lee 2006), neonatal units (Mesman 2008; Vermeulen 2004), security (Patterson et al. 2008), rehabilitation units (Warren and Manderson 2008), and nursing homes (Tinney 2008). But these ethnographies largely focus on locally-trained doctors and other local hospital practitioners.

By contrast, this article focuses on those who have to undergo adjustments to the local ways of practicing medicine. Drawing on the work of Maurice Merleau-Ponty ([1945] 2008), I contribute to the social science literature on the medical professions by conceptualizing the nature of adjustment in medical work. I theorize adjustment as a process of moving constantly between habit and the moment. I explore this empirically by looking at doctors’ adjustments that are discursive and bodily, tied into aspects of status and performance. I argue that looking at migrant doctors’ adjustments foregrounds the locality of medical work; a locality layered with discursive repertoires, bodily movements, architectural details, assessment formats, registration processes, and embedded hierarchies.

This article thus contributes to the ethnographic examination of the local nature of work practices, particularly by adopting the lens of those who are somewhat familiar with their environment and, consequently, highlight what is unfamiliar or different in that environment. In other words, medical practitioners who encounter differences, however small, between “here” and “elsewhere” foreground the local and contextually specific dimensions of medicine. In a related vein, this article highlights the environmentally situated nature of medical practice, where both habits and moments interplay with the multifarious aspects of one’s surroundings. More generally, the following analysis extends the current literature about medical work by considering the nonclinical aspects of medical practice, such as registration and assessments, which required adjustments from the doctors I studied. In making these adjustments, these doctors had to tease out the particulars of practice for examination during assessment, which I illustrate in the penultimate section of this article.

Methodology

I engaged in a three-year ethnographic study of international medical graduates studying and working in three suburban hospitals in Victoria, Australia. I found a sponsor for the research at the hospitals, obtained formal ethics approval from the hospitals’ and university’s ethics committees, and then recruited participants through emails sent to a list of identified international medical graduates employed or studying in the hospitals. Ten participants became involved in the study through this method of recruitment. Further recruitment occurred through “chain referral” sampling as participants introduced me to other international medical graduates in the hospitals.

Recruitment was essentially an open process with little targeting in the initial stages. However, as the fieldwork progressed and themes started to emerge, I approached some international medical graduates directly for participation, with the premise that their stories could enrich emerging ideas. For example, as the focus of the project swung toward the nature of adjustment in the workplace, I realized that I needed to talk to doctors who had been in the system for some time. I sought out international medical graduates nearing retirement, in the private rooms scattered around the hospitals. Similarly, I needed to talk to doctors just beginning their involvement with hospital work, so I searched for doctors participating in orientation programs in the hospitals. I based these recruitment efforts on the doctors’ practices and adjustment rather than demographic details, such as age, gender, or nationality. I thus engaged in a form of theoretical sampling (Charmaz 2006, 96). Altogether, thirty-two international medical graduates employed in the hospitals and more than twice this number of doctors unemployed and studying in various spaces in the fieldwork hospitals participated in the research.

I use pseudonyms in this article for study participants. My fieldwork involved observation, interviews, and textual analysis. In making fieldnotes, I followed the action of the doctors. I paid attention to the practicalities of their work and study, including the places in which they dwelled, the moods or atmospheres of these places, the objects they used, and the people with whom they interacted.

During the course of fieldwork, I conducted thirteen digitally recorded, semistructured interviews with international medical graduates and their colleagues who had become key participants, either because of the amount of time I spent with them or because of the insights they had into their practice. Several interviews took place relatively early in the research, although the majority of recorded interviews occurred towards the end of the fieldwork. On average, these interviews lasted one hour. I used an interview guide derived from analysis I conducted during the first six months of my fieldwork. I adjusted interview questions between and during each interview, taking into account the participant and the setting. I conducted these more focused and in-depth interviews to tease out various aspects of the participants’ practices. I wrote or digitally recorded fieldnotes after each interview, and I transcribed the recorded notes so that I had a written text for analysis.

I analyzed all fieldwork material thematically. I took a two-week break from fieldwork after six months to undertake handwritten thematic coding, note-writing, and tabulating. I subsequently returned to the field to further explore and elaborate on themes that arose. At the end of fieldwork, I recoded and retabulated the fieldnotes and interview transcripts and developed more refined themes, constantly working back and forth with relevant theories and literature.

Background: Medical Migration to Australia

International medical graduates must fulfill the requirements of the Australian medical registration system to be able to work in Australia. At the time of my fieldwork (2007), doctors could take a number of different pathways to employment, largely contingent upon their immigration status, country of training, specialty, or the job location. In some cases, doctors can begin working in a matter of days but, in other cases, they must wait for years, depending on which registration pathway they take. Some doctors never find medical employment.

The doctors I studied received incentives to work in areas of significant workforce shortage in rural and suburban locations, in conditional appointments while undergoing the assessment pathway, or in junior positions while completing a required year of supervised practice (Hawthorne, Birrell, and Young 2003, 7). Doctors with permanent visas who wished to practice in general (non-specialist) medicine in Australia had to pass a series of assessments called the Australian Medical Council (AMC) examinations. They also had to complete a year of supervised training satisfactorily in an accredited hospital post (AMC 2008). The AMC exam is notoriously volatile, with formats and the quotas of doctors able to pass changing from year to year (Groutsis 2006, 62). Revisions to the process, such as the controversial “competency authority pathway” (AMC 2008), highlight the continual evolution of this system.

The pathway to employment for specialists trained outside Australia also depended on their visas, with concessions made for temporary resident specialists willing to work in areas of workforce shortage. Internationally trained specialists underwent specialist accreditation processes separate from the AMC exam. As part of this process, the relevant specialist colleges initially assessed the international medical graduates. If the college deemed that a doctor compared equally to local graduates, the doctor received restricted registration for up to two years to complete supervised specialist practice. If the college deemed that an international medical graduate required further training, the doctor then needed to go through the AMC examination pathway (AMC 2008).

The specialist pathway depended on which specialty the international medical graduate hoped to pursue. Each specialist college set its own accreditation requirements. While international medical graduates wishing to work in dermatology completed the full local examination process, psychiatrists wishing to practice in their field only had to pass an oral examination. Specialties experiencing workforce shortages often had more lenient assessment requirements. For example, in emergency medicine and rehabilitation, doctors only had to sit parts of the exam, while highly competitive specialties, such as ophthalmology, required doctors to start the assessment process from the beginning (AMC 2008).

Even before they reached the hospital, international medical graduates began to navigate specific bureaucratic registration requirements. The Australian registration process is inconsistent and arguably based on politics of exclusion and local protectionism despite claims of openness (Groutsis 2006; Kunz 1975). Many international medical graduates I spent time with, rather than being immobilized by these structural details, tried to find ways to work around and within the registration requirements. For example, most doctors considered how they could secure visas, use their visas, change temporary visas into permanent visas, get into accreditation programs, and find jobs while undergoing the assessments. One Malaysian doctor, Dr. Ambi, ¹ described how he adjusted to the regulations:

I came here in 1988. I had done pediatric surgery. I was very involved in the activities here [observing] and after three years I was allowed to work—I did 150 operations without supervision—allowed to work for 16 months—“there is an appendix here you do it.” I was already involved in getting my specialty recognised—this is five to ten times worse than GP [general practice/family medicine]. Then I tried the [objective structured clinical examination] but because my English is not so good, I didn’t pass. I worked for four years on a temporary visa then because I didn’t pass my exams that stopped. I was happy. I wouldn’t have to see any more books . . . then the GP college offered a scholarship [to return to medical work] . . .

The registration process required in Australia surprised and frustrated many doctors. This process, driven by numerous national policies, involved applications for visas, written and clinical examinations, and finding jobs. Rumor and word of mouth circulated among the doctors concerning the requirements to get through the process quickly and to get a job. Procedures and requirements seemed to change constantly. And they had many different pathways to consider. Just when the doctors grasped one aspect of the registration process, something new appeared. The doctors frequently altered their career goals, their study techniques, and their job-hunting practices in response to shifting registration and employment requirements. Once they obtained registration and jobs, the doctors thought they had finished the hard work, and they assumed they could now continue with familiar forms of medical work. But, as the following sections of this article illustrate, their work had just begun: they had to make adjustments to the local clinical setting to practice medicine effectively.

In a Storm Which Has Not Yet Broken

To explain the doctors’ adjustments theoretically, I draw upon the phenomenological work of Merleau-Ponty ([1945] 2008). In doing so I examine layers of living experience he describes as a system of “self-others-things,” which emerge as one comes into being. Importantly, Merleau-Ponty (2008, 469) places the practitioner firmly within the environment—“I am situated in a social environment.” His practitioner is attuned to the heterogeneous relations in this environment, which he regards as the human and nonhuman worlds. Merleau-Ponty (2008, 374) writes, “I perceive everything that is part of my environment, and my environment includes everything of which the existence or nonexistence, the nature or modification counts in practice for me, the storm which has not yet broken.”

The international medical graduates worked in new hospital environments, the local details of which—the storm—counted for them in practice. To work in this familiar unknown system of self-other-things, the doctors needed to adjust in discursive and bodily ways. They made these adjustments as a constant response to the arrangement of things in their new environments, both the human and nonhuman, including registrations processes, exam formats, paperwork procedures, patients, other hospital staff, and instruments.

The “new” was heightened when doctors first arrived at the hospital, when the clinical arrangements were particularly unfamiliar. Dr. Jiaying, who had held a good position in a “well-respected” hospital in Shanghai, told me about an incident during her first day working as a doctor in Australia. She heard a “Code Blue” (medical emergency) call while working with a resident who had trained in Sri Lanka:

We did not know which direction to go. Usually the hospital has a good team—but we are both new. We did not know the drugs to use—I was not familiar with the drugs. The consultant [senior physician] arrived and said, “Where the hell did you get these people from?” a comment aimed at me and the registrar [consultant in training]. I thought, humpf, a bit offensive. That is a print on my brain. I felt, humpf, I’m usually very confident; I like to be on top. But in the emergency situation you forget to mention what you are doing and you just do it.

Dr. Jiaying’s new environment comprised an assemblage of strange building layouts, drug names, and hierarchical relations. Everything was new (yet somewhat familiar) and in a time of uncertainty she fell back on habit.

Habit was ingrained in the international medical graduates’ styles of medical practice, developed through their education and work elsewhere. Various scholars have used Pierre Bourdieu’s (2000) concept of habitus to explore the habitual nature of medical practice (e.g., Rice 2010; Sinclair 1997), but I return here to Merleau-Ponty, whose notion of a layered body, in the form of a habit-body and body-in-the-moment, allows for a more dynamic understanding of adjustment, not only in regards to bodily adjustments but to other kinds of adjustment that doctors need to make in the hospital.

In Phenomenology of Perception, Merleau-Ponty (2008, 96) describes the body as having two layers: the habit-body and the body-in-the-moment. Habit is developed in the rich environment of practice that becomes the familiar. For the doctors, habit developed in the environments in which they grew up and into, shaped by their various clinical situations, institutions, colleagues, patients, instruments, and so forth. In this article, I use an expanded concept of habit which encompasses not only the body, but also spoken and written words. Dr. Mück recounts how habit is woven from the familiar, created in previous clinical environments:

I got an opportunity to be trained in a bit more relaxed environment where you can practice a lot . . . it means, that learning certain techniques and performing more complicated trials, it was a bit easier . . . I said my advantage was doing that and practicing that in an environment that was not threatened with litigation and of course I changed my practice here when I realized that . . . that was the way how to go [here]. You are completely covered by litigation guidelines, by the protocols and the things, and you change your practice, starting to do the same things as, ahh . . . but . . . I still think that that is defensive medicine, not exactly the right way to go, but that’s the way.

Dr. Mück learned surgical skills in a less litigious environment in Bosnia. He highlighted the difference in the systems of his past and the present, and underscored how the environment is integral to doctors’ work. He described how he changed his practice according to the requirements of the moment. This “moment” entails a practical engagement with the surrounding environment in which one finds oneself at any one time. Again I extrapolate upon Merleau-Ponty’s concept of body-in-the-moment to think about what is required of the practitioners in the moment, bodily and discursively.

Habits and the moment align closely in familiar environments. Adjustments may be minimal or may go unrecognized. The local doctors I met in my fieldsites accepted change in practice as part of gradual learning. A certain taken-for-grantedness of their positions and of their ways of learning existed. They anticipated the field better, their practices attuned to their environment. In strange, or unfamiliar, known environments the moment may be situated somewhere, however slightly, different. Adjustment, I propose, is the movement between habit and the moment, where the past becomes wrapped up in the present, and ongoing oscillation between each exists.

This conceptualization of adjustment, as a threading back and forth, is similar to what others describe as “tuning” (Ingold 2000, 356), “honing” (Sennett 2008, 50), “tinkering” (Knorr-Cetina 1992), “repair-work” (Berg 1996, 514), “accommodation” (Pickering 1993, 580), or “artful juggling, gestalt switching, and on the spot translating” (Bowker and Star 1999, 292). The notion of adjustment draws from many of these concepts which foreground a range of actors, but differs in its phenomenological focus on a constant movement between habit and the moment, taking into account the past and the present in an oscillation that helps to highlight particularities of practice. Importantly, adjustment lies not only in practices themselves but in the responsiveness of practices to the surrounding ecological conditions, which are never the same from one moment to the next (Ingold 2000, 353). For the international medical graduates, the clinical environment involved a constantly moving arrangement of tools, people, paperwork, buildings, assessments, and bureaucratic processes. The following sections examine different aspects of adjustment to this multifarious environment: discursive adjustments, bodily adjustments, adjustments tied to status, and the performative dimensions of adjustment.

Discursive Adjustments

Dr. Mück, an obstetrician, complained about the emphasis on “record-keeping” in the Australian health care system and his frustrations with midwives who wanted everything “written down,” but I heard him emphasize to his registrar the importance of making “adequate” notes. He also warned his younger resident (junior doctor) to be mindful of the medico-legal aspects of his work and the necessities of making careful notations. Working in the system for some time had made Dr. Mück very aware of the need to write things down and he had developed his practice accordingly. He remained critical of these processes, but commented that he had little choice but to change according to the system:

I give my opinion, put it in writing. There are pros and cons, but this is the most efficient. You may think it is better to do it another way . . . you learn not to be judgmental, not to give your own opinion . . . I have changed, not 100%, but I have changed according to local habits.

The local doctors more or less accepted practices such as “writing things down” and other administrative procedures, however begrudgingly. Increasingly, local medical students learn administrative procedures during university, in electronic and article-based forms. Many students and doctors, both locally and internationally trained, found documentation cumbersome and not the “real medicine” that they had dreamed of practicing. Indian-trained Dr. Sadafule told me that as a medical student she had not imagined doing administrative work—the opinion of many doctors, wherever they are trained. Dr. Sadafule believed that international medical graduates found learning about forms and other kinds of administrative techniques more difficult than local doctors, who had been coming to the hospital for years and were more aware of the procedures.

For the local doctors, the discursive requirements of form filling and writing things down was inscribed in habit, a repertoire of standard phrases built up over time. Dr. Youssefian, a mathematician, researcher, and young doctor from Iran, considered the local medical graduates “good” because they organized and documented things easily and better, and were able to handle the enormous number of forms and other bits of administration created in single ward rounds. The paperwork practices of two doctors (one trained locally, one nonlocally trained) during a ward round exemplified the difference between those trained in the local system and those trained elsewhere. The local doctor appeared extremely organized, with her folder full of forms ready to bring out whenever required, such as pathology slips and drug charts. Dr. Munteanu, a pediatrician from Romania who could often be found with patients’ stickers running down his arm, appeared much less efficient in this regard.

As exemplified by one Vietnamese doctor, Dr. Hung, who also had trouble with paperwork, adjusting involved learning the discursive norms of the hospital, not only in regards to paperwork but in other tasks in the hospital that demanded “certain” words for seemingly seamless action. I followed him as he tried to find the radiology department one day to deliver a radiology request slip by hand. Still in his first few weeks in the job, he already knew from fellow junior doctors that this was a more assured way of getting the diagnostic test done, rather than sending the form by the pneumatic tube system. Very soon, however, Dr. Hung became confused about where to go (as did I); each time we asked for guidance to radiology, the staff led us in opposing directions. We finally found the radiologists. They sat in an internal pocket of the radiology department, in a dark film-reading room, their skin illuminated by the images on their computer screens. The radiology registrar (radiologist-in-training) sat at the desk, studying an x-ray. Dr. Hung gave the referral slip to him and presented the case. The registrar appeared to become increasingly frustrated, and his body language suggested that Dr. Hung was not providing the information in a succinct, appropriate manner:

[We wait for a man in white overalls, lounging in his chair, to finish a telephone call. He wheels over and the radiology registrar gives him a very short, concise presentation of the case.]

[The registrar and consultant look at him without saying anything.]

As we left the room a young doctor was waiting by the door with a radiology referral slip in her hands. Requesting radiology services is a disconcerting experience for any junior doctor, but I wondered if this local doctor had better prepared her paperwork and story. I could see that Dr. Hung was upset and I suggested that making a radiology request was very stressful:

Yes, everywhere in Australia it is the same. I don’t understand it. In Vietnam it is very easy to get a test because the doctor makes money from it. Patients get these commonly, for minor things. The radiology companies are outside the hospital and they get money for the patients. Here, very hard.

Dr. Hung had never had to “sell” a patient to radiology before and had therefore not provided the “appropriate” information on the request slip or known how to deliver the “appropriate” radiology room performance. A style of discourse was expected in the hospital between those wanting diagnostic tests and those who could authorize them, a social norm ingrained in how the forms should be filled out and the associated oral performance. During the latter years of medical school and during the early years of medical work, locally trained doctors learn ways to “deal with” particular departments. They learn the tricks of presentation so that when they present referrals to the radiologist, they have an increased chance of having the test done when their consultant demands it to be done. These relations gradually become more seamless and taken for granted over time, as they are refined and learned. In this way, the institution runs smoothly.

For the international medical graduates, learning the local discursive requirements occurred through ongoing adjustments, with varying degrees of success, as they tried, for example, to minimize the time spent writing forms and to maximize their chance of getting the required specialist referral or diagnostic test. To varying degrees, the doctors changed their practices slightly after each resistance encountered. They also learned by watching the locals. For example, Dr. Youssefian wanted to sound more like a natural speaker. He studied how local doctors used different words, different gestures, and he tried to copy the accent. He said, “I try and catch them, but I can’t.” He said that his interactions in Australia were completely different than in Iran—such as presenting a patient to a consultant, or speaking to the patient. As he highlighted, the adjustments that the doctors needed to make to fit into their new working environments were not only discursive but also tied up in bodily practice.

Embodied Adjustments

Like good ethnographers, international medical graduates use skills of observation and mimicry to begin to adjust to local hospital practice, as Dr. Youssefian explained. In their new clinical contexts, international medical graduates observed and copied their local colleagues’ techniques. Another young Iranian doctor told me about difficulties when he started working in a hospital in country Victoria. He found simple things such as taking blood different. He felt he should know how to do these procedures, especially considering his position as a senior resident. He managed by closely observing other people doing simple procedures and sometimes replicating these exactly; in his words, “pretending he knew what he was doing.” In an adult rehabilitation ward I watched a Romanian doctor who had specialized in pediatrics. She observed a junior colleague taking blood from an elderly patient, and she said that this locally trained doctor “took blood much better” than she did, and she wanted to learn his technique. Another doctor in an orientation program for international medical graduates visited the venipuncture clinic and asked if he could observe how to put in cannulas (intravenous devices for administering fluids) and how to take blood. Staff at the venipuncture clinic, who were used to medical students doing this, said that it would be fine. The doctor told me, “the medical students, they know the environment and can learn easily this way.”

While these adjustments were based on observation, it is important to remember that international medical graduates engaged in adjustments that continually formed and moved on from their own previous practices, rather than merely replicating those they copied. Adjustment was a threading movement between the past and the present. Bodily adjustments were made not only in regards to procedures but also in regard to ways of moving through the hospital and in ways of interacting with patients and colleagues. All bodily adjustments were sensory, involving sound, smell, image, touch, and kinesthetic movement. The international medical graduates’ adjustments were constant responses to the arrangement of things in their new environments, both the human and nonhuman.

Adjustment did not always mean acquiring new skills. For example, a Sri Lankan doctor, Dr. Tiruchelvam, did not necessarily consider himself as adjusting to perform more technologically advanced procedures. In fact, he perceived his adjustments as a “downgrade” in a hospital he found resource rich and that used doctors for clerical and simple duties that nonmedical staff performed in Sri Lanka. As a junior member of Dr. Mück’s obstetric team, Dr. Tiruchelvam’s job involved many menial jobs in the operating theater and on the wards. Cannulation (the insertion of an intravenous cannula) was one of them, as was catheterization (the insertion of a catheter). After inserting his third catheter during a morning’s operating list, it was obvious how boring he found this job. With his arms crossed, leaning back on the surgical stool, he told me in a loud whisper that this job was not done by doctors in Sri Lanka. Nurses or medical students performed this job. He believed that his allocation to this job demonstrated how Australia and other rich countries wasted their resources. He said that he had trained to be a doctor, to do “certain things,” and that ultimately here he was doing “other things”:

In our country you train to be a doctor to do doctors’ duties . . . being [international medical graduates] we see the difference . . . at home we totally do the true medical stuff. Here the [junior doctors] mainly do the menial jobs. It’s a waste of training. When you become a medical student in Sri Lanka you have done 100 episiotomies. But I hardly get a chance to perform practical aspects here. I don’t want to criticize the system here. What I want to tell you is the difference.

Pointing to the operation in front of us, Dr. Tiruchelvam said he could assist lying back in a chair operating with his toes. For him, the catheter and catheterization was routine and dull and was beneath him. He demonstrated nonchalance towards his requisite procedural tasks with an arms-crossed, feet-back, laissez-faire attitude—a demeanor interpreted by the other doctors in his team as laziness. Catheterization was part of a long-ago past, a practice he had surpassed in his twenty years of work as a general practitioner (family doctor) in Sri Lanka. He had performed these skills in a very different environment. He noted that “here you are alone. You have to find instruments, gloves . . . this was hard in the beginning. In Sri Lanka you are like a king.”

Dr. Tiruchelvam reiterated the importance of the materiality of local practice and raised another kind of adjustment that many international medical graduates had to make—that regarding their status within the hospital.

Status Adjustments

International medical graduates are often employed in lower positions in the hospital hierarchy than the positions in which they previously worked, and they need to adjust to this change in status. Dr. Tiruchelvam reported being used to a very privileged status in Sri Lanka and adopted an attitude of nonchalance to cope with this change. He said he did not really care about obstetrics and that his junior position formed part of a required supervised year in the hospital before heading onto general practice. Between catheters, he told stories of how many cesarean sections he did in a day in Sri Lanka, or of the time he checked his wife’s blood pressure when she was pregnant and saved both her and his son, using his status as a doctor to get her the treatment she needed. These recounted stories were important in coping with ruptures between perceived abilities and the competencies required of him in the moment.

The doctors articulated a rupture in perceived ability and the actual tasks required of them, but, as evident in the previous section, international medical graduates also assumed the role, on occasion, of medical student, while working as doctors. Inherent tension was evident in this, as the international medical graduates had already been medical students elsewhere. These doctors had passed their qualification exams and proved themselves as doctors. Now they had to learn aspects of medical practice again, learning from medical students, nurses, and other staff on the wards. This required an adjustment of their embodied work—taking blood, for example—as well as their sense of status and professional identity.

The doctors described the mismatch between their status in their home countries and their marginal, medical student–like status as doctors in Australian hospitals as painful and impacting on what it meant for them to be doctors. This disruption reinforces that doctoring is an environmentally situated concern, tied into all of the human and nonhuman relations in a medical workplace. Being a doctor is multilayered; it is not just about action and knowledge, bodily practice, and ways of saying things but also about sense of identity, including status within the workplace. Being a newcomer is difficult when membership has already been gained elsewhere. Learning in a new environment is imbued with precariousness, uncertainty, and vulnerability. International medical graduates were often under scrutiny, from when they entered the registration process and throughout their work in hospitals. As the following section demonstrates, the doctors often had to perform competence and constantly prove themselves as doctors. This performative dimension of practice is another crucial aspect of adjustment.

Performing Adjustment

Sitting in the obstetrics staff room one day, Dr. Mück leaned over for a leftover sandwich and said that foreign doctors are like secondhand cars—examined for all their small cracks before they get roadworthiness. International medical graduates had to continually prove themselves as doctors, as Dr. Kuthala, a Burmese doctor I found studying in the library, explained:

Ahh, yes, that is a small thing regarding the cannulation—when I was in Fiji island we called it Plastocaine. When I worked in New Zealand we called it lua or cannula, and when I came to Australia we call it Jelco. I say “what is Jelco?” . . . a little bit variation from one place to another . . . we have to have patience. . . . I had done thousands and thousands of cannulas in Fiji—nine years—acute case, myocardial infarction. I had to put them in myself, the nurses were so slow . . . this is a small thing, the cannula. We have to have patients and we have to be patient! Here, ahh, I was asked so nice, “have you done before?”, “yes I have done before” . . . that is the usual question they ask, “have you done before?” . . . a little bit asking in front of the patient, asking if you have done it before –after doing, after the performance of that procedure you feel better.

As Dr. Kuthala described, proving competence is a performance. This need to perform doctoring became most evident in the clinical examinations when the doctors needed to explicitly demonstrate their ability to work as medical professionals in Australia. The written exam is an arduous day-long process of answering multiple-choice questions, while the clinical exam is a stressful series of eight-minute mock clinical scenarios. International medical graduates whom I spoke to were certainly aware of the performative aspects of the AMC clinical exam in particular, where particulars of practice need to be teased out to demonstrate competence equivalent to the standard of a recent Australian graduate. South African Dr. van Aarde shared with me his opinions on this style of clinical exam:

You don’t see a patient! They just put a piece of paper up on the wall outside the room and then there is a role-player. They have no idea if I can examine a patient or not. I just have to pretend to listen to the heart sounds but you can’t hear them! You just have to know the theory. It’s a performance.

The doctors learned these “performances” for the clinical exam through repeated practice. Each Thursday night, in one fieldwork hospital, an ever-expanding group of migrant doctors studying for the AMC clinical exam met in a small room near the hospital library to practice scenarios for the exam. During the tutorial, the tutor outlined a clinical scenario and asked for a volunteer to role-play the exam candidate and for a volunteer to critique the candidate. The tutor role-played both the patient and the examiner. During these role-plays, the doctors needed to learn the “style” of the exam. Each assessment station was principally a single-diagnosis scenario and candidates needed to be able to recognize this, and to demonstrate, in eight minutes, their Australian-style clinical practice. The doctors learned the required performance over time, as they took turns role-playing, critiquing each other, pointing out mistakes (often in discrete murmurs to each other during a role-play), and practicing possible scenarios over and over again.

Failure of the doctors to demonstrate “appropriate” interpersonal skills can equate to failing the exam. Tutorials make the importance of this clear to international medical graduates. Polite questions for patients seem rehearsed, unfamiliar situations such as “breaking bad news” memorized, and the inclusion of families and other colleagues in decision making emphasized during each role-play. The doctors needed to prove they had made the adjustment to the “Australian way” of practicing medicine. They aimed to give a performance in which they did not stand out.

One of Dr. Mück’s junior colleagues told me, after completing her obstetrics fellowship exams, that “the best advice I got was to try not to wake the examiner up—they only wake up if you do something really wrong or are really good.” The doctors aimed to appear like local graduates and aligned their bodies accordingly to close the gap between their habit bodies (Merleau-Ponty 2008) and the bodies required of them in that moment.

Adjusting to meet the Australian standard in an examination did not happen easily. One Sunday during fieldwork I stumbled across a group of doctors studying for the first AMC assessment requirement, the written exam. Many doctors in this group were a lot older than those I met elsewhere on the wards, and were historically dense with years of previous clinical experience. The Sunday study group struggled to pass a written medical exam modeled on that given to a final-year medical student in Australia. Their ingrained, specialized clinical pasts made it difficult for them to adjust to the structured multiple-choice format and to remember the more general, medical knowledge they were required to demonstrate.

Some doctors found it hard to give a good performance in the clinical exams; they found it hard to dissect their skills for the purposes of examination. Dr. Mück felt that he could adjust in the everyday of the hospital, but when he came to explaining his obstetric practice in assessment, things fell apart:

In terms of assessment with the college I was assessed close to, ahh, Australian consultant and I needed to achieve the fellowship, of full recognition—the condition was to pass my membership exam and spend two years of advanced training and unfortunately I continued to work full time and I was good in that field but I could not, ahh, manage to . . . achieve that goal, you know, to pass the exam in that period of time required and that’s the reason why five years after working as a senior registrar at the Royal Women’s [Hospital] I needed to change the hospital and come . . . to Hospital X . . . to work in what we called, a hospital in . . . an [area of workforce shortage].

Medical doctor and sociologist of science Michael Polanyi notes the difficulty in making tacit practice explicit because normally we focus our attention on the action and only have subsidiary awareness of the details of our own movements. Being made aware of a process “de-naturalizes” it and makes things—the performance—more obvious (Polanyi 1958, 56). Dr. Mück spoke of the difficulties that many international medical graduates had in dissecting habits and rearranging them for assessment.

In assessment the international medical graduates needed to perform a coherent self, a medical self congruent with a perceived ideal of Australian practice. Rather than the layered self of a doctor who has worked elsewhere and who oscillates between past and present conditions, the doctors needed to arrange, as well as possible, their practice to fit with the expected Australian standard, embedded in assessments. They needed to submerge their own histories, which allowed no space to draw on past experiences. As Dr. Mück’s story shows, the doctors’ own styles of medical practice, however, were ingrained and embedded, entangled with past behaviors, personality traits, situational variants, and cultural norms of previous contexts. This meant that the doctors’ role-plays as “good doctors” often appeared forced. Don DeLillo (1997, 103) describes the paradox of this performance when one of his characters reflects on “playing at being an executive”:

There’s a self-conscious space, a sense of formal play that is a sort of arrested panic, and maybe you show it in a forced gesture or a ritual clearing of the throat. Something out of childhood whistles through this space, a sense of games and half-made selves, but it’s not that you’re pretending to be someone else. You’re pretending to be exactly who you are. That’s the curious thing.

International medical graduates had already adjusted to what was considered an appropriate way of doctoring in another context, but realized that Australia required something different. Yet what was required was underlined by similar duties of care: to try to be a “good doctor.” Many international medical graduates had difficulty in making their own sense of care explicit and in teasing out the particulars of good practice for the examiner to assess; for in doing so, they had to pretend to be exactly who they were.

Conclusions

This article contributes to what appears to be a significant gap in our empirical and theoretical understanding of how practice is adjusted from one work setting to another, in new occupational contexts (Syed 2008, 31; Williams and Baláž 2008, 1924). In particular, my research contributes to our understanding of what it means for medical practitioners to move between clinical contexts. This article expands upon the vast number of anthropological and sociological ethnographies written about doctors and hospitals that have thus far tended to focus on local workforces and have neglected to pay attention to migrant staff ² (although their absence from the literature has been noted [Cassell 1991, 95]). Because of their sense of familiarity and strangeness in new work settings, migrant doctors, I argue, highlight the adjustments that are integral to medical practice. I have developed the theoretical notion of adjustment through the work of Merleau-Ponty, situating it as a movement between habit and the moment. This notion of adjustment can be applied more broadly than medical work, considering that many skilled migrants are now educated and trained in increasingly globalized workplaces that, however, retain local characteristics.

By looking closely at the adjustments that skilled migrants make to local workplaces, ethnographers can learn more about the details of locality that are taken for granted by those dwelling in familiar environments. The article adds to the literature examining the locality of medical practice by looking at those who greet their new workplaces as familiar unknowns. The doctors’ adjustments in this article revealed something about local surgical techniques, drugs used, hospital layouts, instruments, norms of interaction, paperwork practices, and what it means to be “good doctor.” Others have argued that mobility between organizations and crossing contextually different divides can also make more visible the processes of social production (Iedema, Rhodes, and Scheeres 2005, 330) and reveal institutional forces (Gertler 2003, 94). Strangers or newcomers are a source of learning (Bowker and Star 1999, 295; Lave and Wenger 1994, 122). They hold the mirror.

Few traveling doctors I met considered the differences they encountered in practice in advance. They presumed, as I did when working as a migrant doctor (Harris 2011), that medicine is a uniform abstract body of skill that can be transported in a suitcase from place to place. This article contributes to the ethnographic literature that challenges the assumption that medicine entails a universal set of knowledge and practice by emphasizing, instead, through ethnographic examples, that medicine is always local, contextualized, and embedded in complex sets of relations—relations with which practitioners are in a constant state of adjustment.

Another contribution of the article is to expand our notion of medical work by considering exactly what it is that doctors must adjust to and from in moving between contexts. The ethnographic material highlighted the environmentally situated nature of medicine, how it involves registration requirements, assessments, architecture, pharmaceuticals, paperwork, and ways of interacting with patients and local staff—all shaped by legal, economic, and other related factors. The doctors’ process of adjustment was multilayered. Medical practice concerned registration as much as cannulation. Adjustment was not always to patients, as is often discussed in the literature, but also to tools, other staff, and bureaucratic processes. Bodily adjustments involved the ways in which the doctors took blood, inserted catheters, performed surgical procedures, and studied for exams. The doctors observed, mimicked, threaded back from the past, and adapted to the local ways of practice. Adjustments were also discursive, involving an oscillation between words used in previous clinical environments and those considered “appropriate” in the new hospitals. The doctors also needed to adjust to changes in status, a process that had profound effects on their sense of professional identity.

Adjustment, however, was only allowed in particular spaces. The penultimate section of the article shows the difficulties of assessing adjustment in an examination, where performances of good doctoring become paramount amid desires for standardization and norms. In these examinations (and in their hospital work), doctors often needed to ignore what they did in the past, which meant that, paradoxically, a mismatch between the examination process and the practice of being a doctor existed.

International medical graduates and other skilled migrants need to have more space for the past in their present work, with room for the kind of cosmopolitanism that Bruno Latour (in Szerszynski and Urry 2006, 127–28) calls for, where migrants do not need to leave their attachments at the door, where they are not asked to detach themselves from the particular, from particular places, in order to gain cosmopolitan emancipation. Thinking about adjustment as a movement between habit and the moment accepts that doctors come to their new workplaces with their own pasts and their own melodic lines of development (Grosz 2008, 43), that a mess of lines trails behind them, a constellation of stories connecting the doctors to components of a highly complex geography (Permezel and Duffy 2007, 360).

Highlighting the ecological complexities of locatedness, this article considers international medical graduates as adjusting their embodied practice from situation to situation, context to context. This considers the doctors as historical beings who bring their rich embodied lives to work, and whose experiences in current practice intertwine with the past. Adjustment is the work, the social labor required, to go from one setting of medical practice to another. These adjustments help to reiterate how medical practice is woven into the environmental context in which it is situated. These adjustments, occurring in hospitals everywhere, every day, make medicine such a powerful, adaptable, rich, and tenacious discipline (Mol 2002, 115).