The challenges faced by early career international medical graduates in general practice and opportunities for supporting them: a rapid review

Background British general practice is facing a workforce crisis against a backdrop of an ageing population experiencing increasingly complex health challenges. The NHS must increase the supply of GPs, including international medical graduate (IMG) GPs, by increasing recruitment and retention. IMG GPs face distinct challenges during training and their early careers. Understanding these challenges, as well as the help and support offered to early career IMG GPs, is crucial to building and sustaining the general practice workforce. Aim To understand the challenges facing early career IMG GPs and the help and support they can access. Design & setting Rapid review of studies and grey literature on UK-based IMG GPs. Method Six databases were searched. Four websites were searched to find grey literature. Titles and abstracts were screened according to inclusion and exclusion criteria, followed by the full study where applicable. The included studies were analysed using a thematic synthesis approach to identify the challenges faced by early career IMG GPs, as well as the help and support available. Results The database search yielded 234 studies, with 38 additional studies identified via other methods. Twenty-one studies were included in the synthesis. Seven challenges were identified, as well as a range of help and support available. Early career IMG GPs face a range of psychological, social, and practical challenges, which may not be adequately addressed by the help and support currently offered by the NHS. Conclusion Further research is required to understand the extent to which early career IMG GPs access the help and support offered, and if it adequately addresses the unique challenges they face.


Introduction
As the UK's population has grown larger, older, more diverse, and more likely to seek professional medical help, the complexity and volume of work done by GPs over the past two decades has risen substantially. 1 To address this, the NHS must increase the supply of GPs by increasing recruitment and improving retention. 1he NHS's 2016 General Practice Forward View included plans to increase the GP workforce by 5000 by 2021, enabled in part by an international recruitment programme to attract up to 500 GPs from overseas. 2,3This target was later increased to 2000. 4 However, in November 2021 there were 5% fewer fully trained whole-time equivalent GPs in England than 2015, 1 and only 124 GPs recruited through the international recruitment programme were still practising in June 2022. 4MG GPs perform worse than UK-graduate GPs in examinations during training, 5 and are more likely to require training extensions. 6IMG GPs are more likely than UK-graduate GPs to leave the GP Register within 3 years of attaining a Certificate of Completion of Training (CCT) 7 or move abroad. 8he driving factors behind doctors (both IMGs and UK-trained doctors) leaving the UK include feeling undervalued professionally, and purported better working conditions and quality of life overseas. 8MG GPs are more likely to receive complaints, with these complaints more likely to lead to sanctions or warnings. 9onsequently, while pivotal to addressing the NHS's workforce crisis in general practice, IMG GPs face distinct challenges.Understanding these is crucial to identifying how the NHS can offer bespoke initiatives to build and sustain the GP workforce.This rapid review assessed the following: 1. What challenges do IMG GPs face early in their careers?2. What help and support are available to early career IMG GPs, and how do these seek to facilitate their careers?

Study population
The study is about IMGs in the UK or one or more of its constituent countries or The study is about IMGs in multiple countries including the UK (or one or more of its constituent countries) and the information or findings on UK-based IMGs are clearly differentiated from those on other IMGs (in this case only the portion of the study on UK-based IMGs will be read and coded) The study is about IMGs in countries other than the UK or The study is about IMGs in multiple countries including the UK, but it is not possible to ascertain which information or findings are applicable to UKbased IMGs

Language
The study is written in English

Study design
The study consists of the analysis of primary or secondary data, or is a descriptive or factual piece describing developments related to IMG GPs The study is a conference abstract or presentation The study is about the personal opinion of the author, for example in the form of a letter or transcribed lecture

Full text availability
The full text of the study is available

Career stage
The study concerns the early career stage of an IMG GP, defined as IMG GPs who have been working as GPs in the UK for ≤10 years since obtaining one of the following:  S1).The results were imported into Covidence, 10 deduplicated, and screened by one researcher, according to the inclusion and exclusion criteria (Table 1).A random sample of one in five of the studies was independently screened by a second researcher and the results of the screening compared.The inclusion and exclusion criteria were subsequently refined to ensure consistency during screening.
There is no universal definition of 'early career clinicians,' 11 but in the context of this review an early career IMG GP is defined as one who has worked as a GP in the UK for ≤10 years.The included studies did not typically state for exactly how long IMG GPs had been practising, so the researchers' judgement decided whether the study met the inclusion criteria.
Studies were analysed in NVivo (version 12). 12Content relating to the challenges was coded and analysed thematically according to Thomas and Harden's three-stage thematic synthesis approach, consisting of initial line-by-line coding, the organisation of coding into related high-level descriptive themes, and, where possible, the development of analytical themes. 13The final themes were both descriptive and analytical.Information relating to the help and support available was summarised descriptively.

Challenges facing early career IMG GPs
The following seven challenges were identified: 1. Complaints and disciplinary proceedings 2. Different GP consultation models 3. Discrimination and marginalisation 4. Geographical area of practice 5. Language and communication 6. Visas 7. Lack of NHS-specific knowledge Sample supporting quotes are available in Supplementary Table S3.

Complaints and disciplinary proceedings
The relatively high rates of complaints (including from the public, other doctors, and employers) and disciplinary proceedings against IMG GPs were highlighted in two studies. 9,30Black and Minority Ethnic (BAME) IMG GPs were complained about more frequently than other ethnic groups; between 2012 and 2016, 25% of BAME IMG GPs received complaints, compared with 17% of their UKgraduate counterparts. 30Of doctors on the GP register in 2011-2015, both BAME and White IMG GPs were more likely to receive complaints, as well as sanctions or warnings, than their UK-graduate counterparts. 9

Different GP consultation models
Three studies mentioned that some IMG GPs trained in countries with GP consultation models that could appear to be 'dominant' and 'doctor-centred' to their UK colleagues and patients, even if the IMG GPs were clinically competent and practising a consultation style appropriate to their native culture. 20,21,30The studies described the UK-model of doctor-patient relationships as more 'patientcentred' 21 and associated with less expected deference from patients, which IMG GPs may not have been adequately trained for in their home countries. 30

Discrimination and marginalisation
The literature described incidences of IMG GPs experiencing discrimination and marginalisation related to race, ethnic group, or sex at the hands of patients and clinicians. 18,25,27,30In one study, the authors argued that IMG GPs face not only racism but also heterophobia, namely a fear and rejection of difference or 'fear of the other,' which can lead to marginalisation. 27South Asian female IMG GPs described suffering sexist discrimination from other IMGs. 27IMG GPs faced discrimination from White medical colleagues 25 and others in the NHS. 30This could lead to exclusion from job opportunities, such as BAME IMG GPs being prevented from joining 'White' GP practices, although this discrimination was sometimes covert. 30atients sometimes refused to be treated by an IMG GP on the basis of the GP's ethnic group. 27 study of 395 White, native English adults concluded that they preferred UK-graduate GPs to those who graduated in Asia; participants preferred older GPs who had graduated in Asia to younger ones, possibly because they spoke better English and were more aware of cultural norms and customs.18 One study found that building social networks may be difficult owing to cultural reasons, and described the marginalisation of female migrant doctors and those who did not drink alcohol at events.27

Geographical area of practice
27]30 IMG GPs were more likely to work in deprived areas, 8,30 South Asian GPs were more likely to work in deprived working-class areas, 27 IMG (and BAME) GPs worked disproportionately in inner-city areas, ex-mining communities, and coastal towns, 30 and GPs who qualified in Bangladesh, India, Pakistan, and Sri Lanka had more patients than average living in deprived areas. 15Working in more deprived areas was linked to financial, workload, and patient challenges.Remuneration for GPs working in inner-city areas was often less than that of doctors working in more suburban areas. 15The additional funding for GPs in more deprived areas may not be sufficient to compensate for multiple patient comorbidities, which is linked to heavier workloads. 30An analysis of GPs who qualified in Bangladesh, India, Pakistan, and Sri Lanka found that these GPs practised, on average, in areas with more mobile populations with an excess of mental health problems, making it more difficult to meet targets. 15nguage and communication IMG GPs had challenges communicating with native English speakers, even when they performed well on (standardised) English language tests and understood English grammar and vocabulary. 21IMG GPs sometimes struggled to understand idioms and accents, and used phrases translated from their native languages or intonation patterns that native speakers perceived negatively. 21,30According to one study, sociolinguistic errors are judged more harshly by native speakers than grammatical mistakes, meaning that IMG GPs whose first language is not English may unintentionally jeopardise their rapport with patients. 21IMG GPs born in South Asia described being trained in 'the kind of language which is spoken in England' as facilitating their careers and potentially shielding them from discrimination. 27

Visas
Once IMG GPs have completed their GP training, most need to find a GP practice to sponsor their visa, or risk being forced to leave the country. 31IMG GPs can apply for an 'Indefinite Leave to Remain' after 5 years of residency, but GP training takes only 3 years.This problem is unique to general practice, since other specialty training takes a minimum of 5 years. 31A Royal College of General Practitioners (RCGP) study found that few practices were willing to 'sponsor' visas as the process was onerous, and that most practices only started this process once they had identified an IMG GP they wished to recruit, leading to stress and uncertainty. 31

Lack of NHS-specific knowledge
Four studies 8,21,23,30 briefly mentioned that some early career IMG GPs lacked NHS-specific knowledge, including a lack of confidence to practise independently following an induction scheme, 21 little experience in interviewing employers and negotiating job plans, 23 and a lack of knowledge about GP induction and refresher Schemes. 8One study noted that IMG GPs were not perceived to 'know the rules' and did not understand the 'hidden curriculum' for practising 'the art of medicine' in the UK, which included knowledge surrounding personal interactions and clinical practice that was taken for granted (and thus likely uncodified). 30

Help and support available to early career IMG GPs
The studies and grey literature revealed the following range of help and support available to IMG GPs.

Empowerment and leadership skills training
The Next Generation GP programme empowers early career GPs by giving them the belief that they 'can translate insight into impact'. 29The First5 initiative aims to equip early career GPs with the skills to lead the profession. 22tegration with, or representation on, national bodies The RCGP's First5 initiative aims to promote a 'sense of belonging' for early career GPs within the college, 22 potentially tackling feelings of isolation.

Learning and development support
Early career GPs can access support for learning and development, including support for passing mandatory requirements such as revalidation, and Continuing Professional Development (CPD) via the First5 initiative. 22Various fellowships provide support via educational bursaries, protected learning time, and learning and development packages. 29f 8

Mentoring and coaching
Mentorship and coaching can help early career GPs 'get the most out of being a GP' and better understand the varied career opportunities available to them. 22,29tworking and peer support Networking and peer support can help early career GPs feel less isolated, improve their confidence, and provide reassurance by understanding that others may have similar feelings and worries.22,29

Online support
Online support, such as Facebook and forums, facilitated communication and debate, and can be used to link early career GPs to more senior members of organisations. 22

Advocating and lobbying for IMG GPs
Representatives from the Overseas Doctors' Association (ODA) have held meetings with the government, influenced policy, and obtained representation in bodies such as the General Medical Council. 27The British Association of Physicians of Indian Origin (BAPIO) has advocated on behalf of IMG GPs. 16cilitating cultural exchange and collaboration 'Twinning programmes' can facilitate cultural exchange, collaborations in research projects, and learning from each other's experiences, and so on. 20

Linguistic support
Language support, especially related to sociolinguistic and applied language skills (signposting, active listening, and so on), helps IMG GPs consult more effectively. 17,21,23

Practical and financial
This support includes relocation packages, 14 help with accommodation costs, 23 and providing help with paperwork and practical support such as guidance on vaccine requirements. 17This helps IMG GPs understand what is expected of them. 17

Summary
This review identified the challenges facing early career IMG GPs and the help and support available to them.Many challenges are interrelated; for example, discrimination from patients or communication challenges may lead to higher rates of complaints.While there is some overlap between the challenges and the help and support identified, early career IMG GPs deal with complex challenges that may be insufficiently addressed by the help and support offered or perceived to be available.19,30 Eschewing this could lead to retention difficulties, 2 especially given the increasingly competitive international market for doctors. 8he next phase of this project will aim to understand the extent to which early career IMG GPs are aware of the help and support offered, the reasoning behind their (non-)uptake of it, and the help and support they currently access and want to access, including support from non-NHS settings such as informal support networks and support in the countries in which they trained.

Strengths and limitations
To the authors' knowledge, this is the first review focusing exclusively on the challenges faced, and the help and support accessed, by early career IMG GPs in the NHS.It is timely in view of the ongoing workforce challenges in general practice, and will be used to inform a qualitative study about the challenges faced by IMG GPs.
The literature search was truncated owing to time and resource constraints.While there was no quality appraisal of the studies, they were all either peer reviewed or published by public bodies.The studies Jager A et al.BJGP Open 2023; DOI: