International medical graduates and quality of care

British medicine and the National Health Service, probably like their counterparts in the USA, have had a complex and at times fraught relationship with international graduates.1 Within the UK, the pattern of simultaneous dependency and denigration of international medical graduates has a long history.2 Such graduates have traditionally worked in areas that were unpopular with British graduates—primary care in inner city areas, ex-mining communities, and specialties such as psychiatry and geriatrics.3 The denigration has always centred around duplicitous undertones of poor quality of care provided by the graduates based on anecdote rather than any research evidence. The tendency has always been to consider international graduates, especially if they have come from non-Western countries, to be less qualified than local graduates and by implication less likely to provide good quality care.4

It is therefore refreshing that Tsugawa and colleagues (doi:10.1136/bmj.j273) have attempted to address whether quality of care delivered by general internists in US hospitals differs between international graduates and graduates of US medical schools.5 They conclude that it doesn’t. Older patients cared for by international graduates did as well or better than others cared for by US graduates. The paper is by no means definitive, and like much research using administrative datasets there are problems with its assumptions. For example, in a healthcare setting it is virtually impossible to attribute patient outcomes to individual doctors, who invariably practice as part of a team, yet this is precisely one of the assumptions that the authors make.

However, the value of the paper is in identifying areas for further research in the UK and other countries where international graduates make up a substantial proportion of the medical workforce. In the UK, for example, researchers could usefully explore the relationship between patient outcomes and the place of qualification of primary care doctors, using datasets from the Quality and Outcomes Framework.6 It is only by building such a body of research that we can reduce the emphasis placed on anecdote and move on to answer the important questions that will help shape evidence based policies in workforce planning, distribution of the physician workforce, and immigration. This might be highly relevant in the US following President Trump’s recent travel ban and in post-Brexit Britain.

However, there is a more general point that needs to be made when interpreting research like this. It will probably never be possible to prove that one group of doctors is any better or worse than any other group. The factors that contribute to patient outcomes are too complex and cannot be brought down to a simplistic binary conclusion as to whether or not quality of care is related to place of qualification. As welcome as Tsugawa and colleagues’ research methods are, the problem we are dealing with is prejudice against a group of doctors who take on unpopular roles in developed countries. More often than not international graduates work in areas that are low priority, insufficiently resourced, and high need.7 Tsugawa and colleagues’ research unsurprisingly reveals that patients treated by international medical graduates were more likely to be non-white, have a lower median household income, Medicaid coverage, and more comorbid conditions.5

Migrant doctors are needed because policy makers are unwilling to take the measures required to promote self sufficiency in medical labour. This would take the form, for instance, of investing in training more doctors, paying them more to do unpopular work, or demanding that medical graduates take on specific roles for a period of time after graduation.

No research can overcome the ingrained prejudice faced by migrant doctors. They are stigmatised because they are marginalised and powerless. So, for example, they have a much higher failure rate in postgraduate examinations, even after controlling for factors such as academic ability.8 They are more likely to be brought before regulatory bodies and be disciplined, not because they experience more complaints but because their employers are more willing to use formal procedures to deal with problems at work.9

What the medical profession and their regulators should do is recognise the vital role that international graduates play in the health system. They are part of the solution rather than a problem to be dealt with. We doubt many international graduates will be surprised at Tsugawa and colleagues’ conclusions. And therein lies the problem.