Welcoming international medical graduates into the UK general practice workforce: A sociocultural perspective

Abstract

Welcoming international medical graduates (IMGs) into UK general practice presents various sociocultural challenges. Cultural differences, language barriers, and unfamiliarity with the UK healthcare system can hinder seamless transition of IMGs into the workforce. To welcome IMGs effectively, it is crucial to bridge any cultural divide and foster cultural competence among both IMGs and their UK counterparts. Encouraging cross-cultural communication and providing cultural sensitivity training can help in building mutual understanding and respect. Embracing diversity within the healthcare workforce can lead to enhanced patient care and improved cultural competence.

The benefits of welcoming IMGs into UK general practice

Diversity in the medical workforce can bring numerous benefits to UK general practice. IMGs play a crucial role in enhancing cultural competence, enhancing patient care and addressing workforce shortages.

Cultural competence and patient care

International medical graduates bring a diverse perspective that enriches patient care in the UK. By understanding a wide variety of cultural backgrounds, languages, and traditions, these professionals can effectively communicate with, and treat patients from, multicultural populations. This cultural competence helps create a more inclusive healthcare environment where patients feel understood and respected, leading to better health outcomes and patient satisfaction. Recognising and valuing the unique perspectives and experiences that IMGs bring, can help UK general practice thrive as a more diverse and inclusive environment.

Addressing workforce shortages

Welcoming IMGs into UK general practice is helpful in making up for a shortage of healthcare professionals, particularly in underserved areas. IMGs fill gaps in the workforce, ensuring that patients, particularly in rural and remote regions, have access to essential medical services. IMGs improve the capacity of the healthcare system to meet the diverse healthcare needs of the population and foster a more inclusive and effective healthcare system.

Understanding the journey of IMGs

IMGs, as defined by the General Medical Council (GMC), are ‘doctors who gained their primary medical qualifications outside the UK, European Economic Area (EEA), and Switzerland, and who do not have European Community rights to work in the UK’. These doctors are also sometimes referred to as non-UK-trained graduates. Historically, IMGs have been an essential in making up for a shortfall in the number of doctors needed to meet the demands of the National Health Service (NHS) (Morrow et al., 2013). Pettigrew (2014) noted that the ongoing contribution of health professionals from abroad has been responsible for the sustainability of the NHS since its inception in 1948. According to the GMC, over half (52%) of doctors joining the medical register in 2022 were IMGs with a large proportion in general practice. The GMC, in its 2023 annual workforce report, highlighted that the number of IMGs joining the general practice workforce has almost tripled since 2018.

However, IMGs are likely to face a lot of sociocultural, psychological, emotional, and educational challenges compared with their UK counterparts in their training, the healthcare system, the doctor–patient relationship, and working in the UK. IMGs navigate a complex journey in contributing their expertise effectively, from adapting to a new healthcare system to understanding the nuances of patient care in a different cultural context. Hamarneh (2015) reported on the challenges for IMGs practicing in a new country with a different culture, sets of values, and belief systems, which can in turn impact significantly on the service provided to NHS patients. Although the knowledge of medicine is the same across the world, learning medicine in one place and practicing in another, different cultural setting and healthcare model presents challenges. IMGs working in UK general practice and the wider NHS are faced with the challenges of integration and fitting into a new, different workplace culture. Slowther et al. (2012) reported that IMGs can face difficulties in their workplace during training and clinical practice from a lack of familiarity with UK ethical and legal standards. It follows, in turn, that the NHS faces some challenges when taking on IMGs, unfamiliar with Britain’s medical traditions.

A well-coordinated multifaceted approach with different carefully selected activities is required to address these challenges. There are interventions in place to address some of these challenges, but there remains an increasing need for better insight and understanding of cultural differences and their impact on IMGs working within UK general practice. This insight might improve understanding of the IMG experience and the adaptations required to support transition into UK general practice. Equally, better understanding could help narrow the attainment gap between IMGs and UK-trained medical graduates in postgraduate examinations. It could also increase awareness and ‘cultural competence’ amongst colleagues in the workplace and foster better relationships with educators and supervisors.

Morrow et al. (2013) reported that some of the challenges experienced by IMGs in the UK related to Hofstede’s dimensions of power distance (for example, concerning workplace hierarchies and inter-professional relationships), uncertainty avoidance (for example, in ways of interacting) and individualism/collectivism (for example, regarding doctor–patient/family relationships and the assertiveness of individuals). Verma et al. (2016) identified similar themes and their impact on IMGs’ performance in clinical skill postgraduate medical examinations using Hofstede’s cultural dimension framework.

Hofstede’s cultural dimensions

Geert Hofstede developed Hofstede’s cultural dimensions theory in 1980 as a framework to understand (measure and compare) cultural differences and etiquette across different countries. This framework helps facilitate communication across different cultures, cross-cultural psychology and international management.

Hofstede (1980) defines culture as ‘the collective programming of the mind which distinguishes the members of one group from another’. The framework describes the ‘effects of culture on the values of its members and how these values relate to the behaviour of people who live within a culture.’

According to Geert Hofstede’s cultural dimensions theory (1980), peoples’ values in the society/country can be differentiated along four dimensions (see Fig. 1 and Table 1):

Figure1. The six Hofstede’s cultural dimensions.

Table 1.

Definitions and examples of Hofstede’s cultural dimension.

Cultural dimension	Definition/characteristics	Examples
Power distance	The extent to which power is distributed within an organisation/society. High : acceptance of hierarchical order Low: distribution of power and demand for justification of inequalities of power	High: Latin, Asian, French, and African Low: Anglo, Germanic
Uncertainty avoidance	The extent to which a society/an organisation deals with flexibility, change, and uncertainty Strong: maintain rigid codes of belief and behaviour, intolerant of unorthodox ideas Weak: more relaxed attitude	Strong: Latin, Japanese, Greece, and Germanic Weak: Anglo, Nordic, Chinese, Denmark, and Hong Kong
Masculinity/femininity	Masculinity: Ambition, competition, heroism, material rewards for success Femininity: modesty, quality of life, caring for the weak, and cooperation	Masculinity: Japan, US, Austria, Italy Femininity: UK, Sweden, Norway, Netherlands
Individualism/collectivism	Individualism: loose ties between individuals, emphasis on ‘learning how to learn’ Collectivism: strong, cohesive in-group, emphasis on ‘learning how to do’	Individualism: UK and other developed countries Collectivism: less developed and Eastern countries
Long/short-term normative orientation	High: pragmatic approach Low: prefer to maintain time- honoured traditions and norms while viewing societal change with suspicion (Normativeness)	Long-term: China and Japan Short-term: US and Canada
Indulgence/restraint	Indulgence: allows relatively free gratification of basic and natural human drives related to enjoying life and having fun Restraint: suppresses gratification of needs and regulates it using strict social norms

Small/large power distance index

Weak/strong uncertainty avoidance

Masculinity/femininity

Individualism/collectivism

However, Hofstede and Minkov (2010) in their subsequent studies conducted across 93 separate countries confirmed the existence of the initial four dimensions and identified two additional dimensions:

Short/long-term normative orientation

Indulgence/restraint

Impacts and implications of cultural dimensions on IMGs

Morrow et al. (2013) suggested that cultural issues constitute a significant aspect of the adaption of IMGs to work in the NHS. They identified and demonstrated the significance of understanding a doctor’s cultural norms as they relate to learning and clinical practice for IMGs. They established a need for individualised initial and ongoing support, an iterative learning process throughout training, as well as the need for awareness that IMGs are not a homogenous group of professionals. Using the Adjustment–Effort–Performance model, Al-Haddad (2023) and Nolan and Lang (2022) expanded on how sociocultural adjustment is the key to good performance at work.

It is well known that IMGs perform less well than UK-trained graduates in many postgraduate examinations. This difference in performance – both computerised knowledge-based tests and bedside clinical skill examinations, is described as ‘differential attainment’. Verma et al. (2016) summarised the impact of culture on examination performance using Hofstede’s cultural dimension framework. In their study, it was revealed that the ‘patient-centred approach’ style of the doctor–patient relationship expected of doctors practicing in the UK emanated from the Western culture and may be a less prominent feature of medical communication in many other cultural backgrounds. Other researchers also found that a patient-centred approach may be impacted by communication differences between doctors from different cultures. Fiscella et al. (1997) suggested that some IMGs may struggle to communicate emotional support to patients for fear of encroaching on gender or social boundaries. Similarly, Hall et al. (2004) and Slowther et al. (2012) found that some IMGs may be seen to have a paternalistic approach toward patient care or family involvement in patient care.

Furthermore, Pilotto et al. (2007) highlighted the concept of cultural differences in perceptions of disease, teaching, and learning, while McCullagh (2011) emphasised the subtle impact of culture on communication skills, such as understanding colloquial language, non-verbal communication, developing an awareness of politeness and respect, and reflective practice.

In their study, Verma et al. (2016) discovered that IMG consultation styles demonstrate characteristic features of high-power distance societies which impacted rapport building with the patients. This finding correlates with the study of Meeuwesen et al. (2009) on ‘communication between GPs and patients’ where doctors and patients from high-power distance societies have more fixed roles with little flexibility to exchange unexpected information and doctors were seen as ‘demigods’ and their ‘authority’ could not be questioned by the patient. Unsurprisingly, IMGs who obtained their primary medical qualification from high-power distance countries, are hierarchical and more dissociated from their patients because they are more likely to see themselves as ‘experts’ in positions of responsibility and authority. They appear to take control of the consultation by frequently interrupting the patient or taking responsibility away from the patient. Their consultation style is usually more rigid, and doctor-centred, with a management plan that is often not shared with the patient.

Verma et al. (2016) pointed out in their study some of the challenges that may accompany a consultation where there is a power distance mismatch between the doctor and the patient. For instance, a patient from a low-power distance country expects to be more involved in their care, and is more inquisitive, something a doctor trained in a high-power distance country could find challenging. Another example worthy of note is that the UK healthcare system is set up to work in collaboration with allied health professionals across many multi-disciplinary teams in a non-hierarchical version. IMGs from high-power distance countries where there is greater differentiation between health professionals, may find this particularly challenging. They may not have good knowledge of the unique roles and responsibilities of other professionals, and how best to utilise the skills of others to benefit the patient. They may also be perceived as poor team players because they come from a culture where the consultant decides for the team, in a top-down hierarchical structure.

According to Hofstede (1980), high uncertainty avoidance countries have a lower tolerance for uncertainty and tend to pay less attention to rapport building through nonverbal communication, such as maintaining good eye contact. Reports from the Meeuwesen et al. (2009) study suggest that candidates from low-uncertainty avoidance countries had more eye contact and were interested in building rapport with patients. Moreover, managing and tolerating uncertainty is an essential skill a doctor must develop and possess to navigate the corridors of UK General Practice as a cultural norm. Hence, IMGs trained in a country with high-uncertainty avoidance may struggle to manage uncertainty during such consultations as opposed to their counterparts from low-uncertainty avoidance countries.

Another domain within Hofstede’s cultural dimension framework that is relatable to my experience with IMG GP trainees is individualism/collectivism. Countries/societies where individualism is the cultural norm have loose ties between individuals and this allows a person to act on his/her initiative and be more assertive. Hashim (2017) suggests that doctors from highly collectivist countries could be perceived as less confident, and this may become more obvious when working in countries with high individualism such as the UK. In my experience as a training programme director, some trainers have expressed concerns about some of their IMG trainees coming across as lacking self-confidence and being less assertive, particularly when formulating management plans. Often, they are seen to be waiting on their trainers/supervisors to be instructed on what they can and cannot do and seem not to act on their own initiative. This is a feature of a highly collectivist society where the emphasis is on being a good member and learning ‘how to do’ as opposed to a highly individualist society where the emphasis is on being a good leader and learning ‘how to learn’.

Towards resolution

Navigating the transition into the complexities of the UK healthcare system can be challenging for IMGs. To facilitate a smoother transition process and support their professional growth in UK general practice, certain recommendations can be put in place. These must continue to prioritise the essentials and address the evolving needs of IMGs. These actionable suggestions aim to enhance the transition experience for IMGs, ensuring a welcoming and conducive environment for their practice. Rothwell et al. (2013) proposed that a lack of a support framework with adjustment issues playing a role in the over-representation of IMGs’ referrals to the GMC. Therefore, creating an inclusive and supportive environment is essential for retaining IMGs in UK general practice.

However, with all the support interventions available to ease the transition of IMGs into the UK healthcare workforce, their success or effectiveness partly hinges on the engagement of the individual doctor and readiness to own the process. IMGs must be determined to engage in continuing professional development, develop strong communication skills, embrace mentorship, and seek guidance from experienced colleagues.

Cultural adaptation and training requirements

Cultural adaptation plays a crucial role in the successful transition of IMGs into the complex UK healthcare environment. Cultural differences can impact patient care, medical decision-making, and team dynamics within the practice. Understanding and respecting diverse cultural norms and patient beliefs is essential for providing patient-centred care.

IMGs may require additional training or support to thrive in the UK healthcare system. Structured training programmes or eLearning modules focusing on cultural competence, inter-professional collaboration, and NHS structure can be provided to aid IMGs in navigating the nuances of UK general practice. IMGs can enhance their adaptability and effectiveness in delivering patient care by embracing continuous learning and cultural immersion.

In essence, addressing language barriers, promoting cultural competence, and providing tailored training are crucial steps in supporting the successful immersion of IMGs into the fabric of UK general practice. By recognising and mitigating these challenges, IMGs can contribute more meaningfully to the diverse healthcare landscape and enrich the patient experience.

Bridging the gap through collaboration

Collaboration between IMGs and their colleagues is key to a successful transition in UK general practice. Building strong relationships based on mutual respect and understanding can create a supportive environment within which IMGs can thrive. Having a suitable peer mentor who has gone through similar experiences and the provision of regular check-ins and support at difficult times can be very reassuring for IMGs. Healthcare teams can leverage the unique strengths of IMGs and promote a culture of inclusivity and collaboration by fostering open communication and sharing knowledge.

Cultural sensitivity and awareness training

Cultural sensitivity training programmes are essential for fostering an inclusive and supportive environment for IMGs in UK general practice. These programmes aim to educate healthcare professionals on diverse cultural practices, beliefs, and communication styles. This training can increase the awareness of medical educators and supervisors about the expectations and experiences of IMGs who may not be familiar with working in groups or being independent, active learners. Healthcare teams can better understand and support the unique needs of IMGs by promoting cultural awareness and sensitivity, ultimately improving patient care outcomes and increasing collaboration between team members.

Policy changes and supportive measures

Policy adjustments and supportive measures play a vital role in streamlining the transition of IMGs into UK general practice. Rothwell et al. (2013) stated unequivocally that healthcare policies that influence recruitment from overseas and the enabling immigration policies are key responsibilities of the government, while the regulators develop standards and employers implement and maintain fitness to practice. Prioritising the implementation of clear guidelines and regulations that specifically address the needs of IMGs can significantly ease their transition.

Providing tailored support through mentorship programmes, buddying schemes, language assistance, and career development guidance can enhance IMGs’ confidence and competence within the UK healthcare system.

Conclusion

We open doors to a wealth of experiences, knowledge, and skills that enrich the healthcare landscape by welcoming IMGs into UK general practice. Embracing diversity in medical teams not only enhances cultural competency, but also leads to improved patient outcomes and a more inclusive healthcare environment for all.

Despite the challenges, supporting the IMGs’ transition into UK general practice is a rewarding endeavour that promotes collaboration, innovation, and a deeper understanding of global healthcare practices. As we strive for excellence in healthcare delivery, embracing diversity in medical professionals becomes not just a choice but a necessity for building a robust and inclusive healthcare system.

Adopting and supporting the successful transitioning of IMGs into UK general practice is vital for fostering a truly diverse, competent, and sustainable healthcare workforce. By welcoming IMGs, the UK healthcare system gains valuable perspectives, skills, and cultural awareness that enrich patient care and community health outcomes. Ongoing support and collaboration are essential to streamline the transition process and ensure IMGs feel valued and empowered in their roles. Every effort to create a welcoming environment for IMGs in trusts, GP surgeries, primary care networks, and integrated care systems is a step towards a stronger and more inclusive healthcare landscape.

Key points

IMGs bring a more diverse perspective and enrich patient care in the UK

IMGs are likely to face sociocultural, psychological, emotional, and educational challenges in training, the healthcare system, the doctor–patient relationship, and when working in the UK

Hofstede’s cultural dimension framework can be used to measure and compare cultural differences and etiquette across different countries

Cultural adaptation plays a crucial role in the successful transition of IMGs into the UK healthcare environment

By welcoming IMGs, the UK healthcare system gains valuable perspectives, skills and cultural awareness that enrich patient care and community health outcomes

Footnotes

ORCID iD

Dr Samuel Ilori

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