Migration of doctors and the “fitness to practise” processBMJ 2011; 342 doi: http://dx.doi.org/10.1136/bmj.d1641 (Published 05 April 2011) Cite this as: BMJ 2011;342:d1641
- Marcella Nunez-Smith, assistant professor of medicine
One of the more controversial aspects of the migration of doctors is whether international medical graduates offer the same quality of care as doctors who train and practise in destination countries. This debate is fuelled by the increasing dependence on doctors who were trained abroad—a quarter of practising doctors in the United States attended medical school in another country, and recent policy changes in the United Kingdom have led to a greater reliance on doctors who were trained abroad in the NHS. Across countries, the “fitness to practise” process or its equivalent, which investigates and adjudicates on concerns about the fitness of individual doctors to practise medicine, is widely held as the great quality arbiter, protecting patients from unfit doctors. In the linked study (doi:10.1136/bmj.d1817), Humphrey and colleagues assess whether country of medical qualification is associated with high impact decisions (the most severe forms of censure) at different stages of this process after allowing for other characteristics of doctors and inquiries.1
The process of licensure for doctors migrating to developed countries is rigorous. For instance, in the US the Educational Commission for Foreign Medical Graduates (ECFMG) certifies international medical graduates through verification of educational credentials in the source country and pass rates on the first two steps of the US Medical Licensing Examination. All international medical graduates must then graduate from a residency programme in the US to be eligible for full licensure. The UK General Medical Council (GMC) similarly oversees a process of registration and licensure for migrating doctors, although eligibility criteria vary by the country of training. Despite the best efforts of licensing bodies, unfit physicians—trained domestically and abroad—enter the workforce. The question remains whether the review and adjudication process is fair and equitable in the context of an increasingly diverse workforce.
Humphrey and colleagues found that medical qualification outside the UK was associated with high impact decisions at each stage of the fitness to practise process, even when controlling for inquiry related variables and other doctor related demographic characteristics.1 This is an important contribution to the literature, given the observed inconsistencies in relevant research to date. One single state study in the US also found that international medical graduates, when compared with US medical school graduates, were more likely to experience licence revocation, practice suspension, probation, and public reprimand,2 all equivalent to the high impact adjudications described by Humphrey and colleagues.1 However, another single state study in the US found no such association.3 Additional research on the association between other doctor related characteristics, such as ethnicity, and the fitness to practise process is needed.
Why might the high impact decisions be more common in foreign trained graduates? With regard to the question of quality, recent research in the US and Canada found that doctors who trained abroad had similar or better clinical outcomes than those who trained domestically.4 5 Yet research in Australia showed that patients assess foreign born doctors as less competent and trustworthy than native born doctors or those trained in a developed nation (regardless of country of origin) when all other characteristics are constant.6 Consistent with these findings, non-native doctors have reported racial and ethnic discrimination at work in the US.7 This interpersonal bias towards foreign doctors may manifest as a lower threshold for complaints by patients and others. A workplace climate that is hostile and discriminatory towards foreign doctors could also influence their performance and evaluation.8 Certainly, the potential effects of discrimination should be included in our discussions as we explore options to expand our healthcare workforce globally.
Although discrimination may contribute to the differences seen by Humphrey and colleagues,1 we should consider other potential causes. Firstly, a history of unprofessional behaviour in medical school has been associated with high impact decisions among native-born doctors in the US and the UK.9 10 Perhaps the system identifies a higher proportion of students with these poor prognostic characteristics and dismisses them earlier in the domestic training process compared with students with similar characteristics who train abroad. Secondly, international medical graduates are more likely to work as generalists and often practise in designated healthcare shortage areas and rural locations.11 Practice patterns may be an important consideration when assessing outcomes of fitness to practise proceedings at the GMC and elsewhere. We should also think about how the sociocultural differences between patients or peers in destination countries and foreign doctors might affect the disciplinary process.
Humphrey and colleagues present compelling evidence that should stimulate action within the profession. The GMC can be a model for other oversight bodies in the area of data collection, transparency, and public accountability. We should encourage a self auditing process within the GMC and similar bodies, including review of practices and procedures. We also need to evaluate diversity, or lack thereof, within the leadership and membership of oversight boards.
Furthermore, the system may be broken on a larger scale. How do oversight boards measure and benchmark disciplinary performance? The discipline process has always been a reactive one, and this may have partly resulted in the observed inequities. The system relies heavily on external reporting, which does not prevent initial patient harm and is subject to a host of introduced biases. As our geographical borders become more porous and diversity increases within the workforce, oversight bodies will play a pivotal role in securing high quality care and professional equity.
Cite this as: BMJ 2011;342:d1641
Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.