Intended for healthcare professionals


It is time to accentuate overseas doctors’ positives

BMJ 2016; 353 doi: (Published 21 April 2016) Cite this as: BMJ 2016;353:i2148
  1. Subodh Dave, clinical teaching fellow and consultant psychiatrist, Royal Derby Hospital; honorary associate professor, University of Nottingham
  1. subodh.dave{at}


International medical graduates bring a wealth of experience to the NHS but this is rarely acknowledged, writes Subodh Dave

It is estimated that over a third of the 150 000 or so doctors in the NHS received their primary qualification outside the United Kingdom.12 These doctors are often referred to as international medical graduates (IMGs), although the General Medical Council (GMC) excludes doctors from the European Union from this group.

IMGs as a group, whether or not from the EU, face difficulties common to migrant doctors across the globe. They perform poorly in high stakes examinations and are more likely to be referred to regulators.3 High profile cases of IMGs’ poor performance have led to negative headlines in newspapers,4 and discussions about IMGs are usually framed in a negative way.

This is unfortunate and unfair. It costs about £250 000 (€316 860; $354 670) to train a doctor but it is rarely acknowledged that by importing nearly 60 000 doctors, the NHS has saved £15bn. Moreover, patient outcomes for those treated by IMGs have been reported to be better or as good as those treated by non-IMGs.5

Given that the NHS employs IMGs from scores of countries across the world, one would expect that there would be a mechanism to tap into the international experience they bring. However, in my role visiting trusts around the country as associate dean, trainee support, for the Royal College of Psychiatrists I have been struck by how difficult non-IMG doctors find it to initiate conversations with their IMG colleagues, let alone tap into their international experience.6

Identifying IMGs’ strengths

The practice of focusing on patients’ strengths is well established in clinical medicine, particularly in psychiatry, yet IMGs routinely report the failure of their employers to take their “IMGness” into account when designing their individual learning plans. IMGs, mainly from the developing world or eastern Europe, have had experience of working in relatively resource poor settings and of managing patient expectations and logistics. It is not uncommon for doctors in such settings to have caseloads four to five times bigger than is average in the UK.

In such settings rationing is more explicitly acknowledged and there is a more upfront discussion about the need for the patient to use resources within their community. This leads to more direct engagement of family, friends, and the patient’s immediate community—who then drive social rehabilitation and recovery as much as the treating physician. This leads to a more genuine practice of community medicine than in the developed world where treatment often involves a physician, community nurse, and a social worker attempting to replicate (usually unsuccessfully) a “community” for their patient.

Services in the UK are often hostage to fixed times and human resource allocation while in many low and middle income countries services are more able to match supply to demand by deploying human and other resources flexibly.

“Jugaad”—the ability to “make do,” a characteristic South Asian attitude—has become a buzzword for management schools across the world.6 And yet the NHS, with thousands of GPs and specialists from South Asia, has failed to capitalise on the entrepreneurial spirit that “jugaad” encapsulates. A new report by the BMA highlights the feelings of IMGs—from a diverse range of countries—that the NHS fails to utilise and value their international experience.7

My own personal experience is that, despite having worked at very high levels in the NHS over the past 20 years, I have never been asked how my training and experience in India could help improve services in the NHS.

What can non-IMG doctors do?

Be curious about your IMG colleagues. And be empathic. Ask them about the health system they’ve come from, what strengths they bring to their training and service environment, just as they identify gaps in their learning. This process of reflection should aid in inculcating confidence in your IMG colleagues at a time when they are coping with familial, cultural, and professional upheaval.

Use praise sincerely but deliberately. Awareness of their strengths will help IMGs deal with the real differences in clinical and educational practice that exist between the UK and other countries.

Finally, be aware of and promote IMG role models. Far too often IMGs are caught in a cycle of negative narratives, believing that exams are stacked against them thus significantly denting their confidence. At the Royal College of Psychiatrists Awards in 2015 it was inspiring to see that IMGs were over-represented in the nominations for various awards. Positive role models create aspiration and are the best antidote to a sense of embitterment and injustice.


  • I have read and understood BMJ policy on declaration of interests and declare the following interests: as associate dean for trainee support I have actively promoted the welfare of trainees needing support including international medical graduates.