Systemic Barriers Facing Internationally Trained Doctors and Pathways to Meaningful Reform
- 6 days ago
- 7 min read
Updated: 4 days ago
Dr. Omosefe Christina is a Medical Doctor, Entrepreneur, and Founder of Elite Exams. She blends frontline clinical practice with medical education and community programmes to help International Medical Graduates (IMG) and African families flourish in their careers and communities in the UK.
When I began mentoring internationally trained doctors in the UK, I encountered a physician who had previously served as a senior clinician overseas, leading emergency units, managing teams, and saving lives on a daily basis.
Six months after her arrival, she struggled to adapt to the new system. Eighteen months later, she did not pass her postgraduate examination. This outcome was not due to insufficient clinical knowledge, but rather a lack of familiarity with the system, unstated expectations, poor understanding of the curriculum and assessment structures, local shorthand and medical abbreviations, and implicit cues presumed to be universally understood. She arrived and immediately sought to meet the expectations for NHS service delivery. This scenario exemplifies the reality of many IMGs and why differential attainment remains high. According to a 2024 article by Lane, Shrotri, and Somani, many international medical graduates in the UK face challenges adapting to the system, including working in isolated roles, receiving little constructive feedback, and having few opportunities for career progression. These factors can affect their ability to pass postgraduate examinations.
The unspoken curriculum in medical training
According to NHS Employers, 4,880 internationally qualified doctors left NHS practice in 2024, representing a 26% increase from 2023, when 3,869 left. This highlights ongoing shifts in the NHS workforce and the significant role of internationally trained doctors.
These doctors bring extensive international experience, often while managing the challenges of migration, relocation, licensing examinations, and family obligations. Nevertheless, they are expected to perform at a comparable level to their UK-trained peers within weeks, despite being unfamiliar with the healthcare system.
The professional exams they sit and the assessments they undergo were designed for a different candidate, those educated, socialised, and trained in the UK. In such instances, success assumes:
Familiarity with local communication and consultation styles
Understanding how the NHS navigates authority, when to escalate, how to raise concerns, and what "speaking up" looks like in practice
Understanding of reflective learning and its application in healthcare education
For international medical graduates, these are new territories to add to their steep learning curve.
A 2025 systematic review in Frontiers in Medicine examined equity issues for internationally trained doctors. The review found some evidence that induction programs could provide beneficial support, however, it highlighted that access to these structured programs varies significantly across NHS trusts, resulting in inconsistent experiences for IMGs. The authors also noted limited evidence that current induction programs consistently improve adjustment or performance, indicating that both inconsistent provision and uncertain impact remain key challenges.
Frequently, internationally trained doctors devote their initial years to adaptation rather than professional advancement. This process often involves extensive self-directed study to understand expectations and regulations, even as they are evaluated by these standards in both peer and formal assessments.
This situation does not provide a level playing field, rather, it creates a delayed start for internationally trained doctors.
The myth of "merit"
When disparities in examination results emerge, common explanations include language barriers, communication styles, and "cultural fit." These explanations are convenient because they place the responsibility for adaptation solely on the internationally trained doctor. However, they are incomplete, as they overlook a critical issue, the system evaluates performance without critically assessing whether its metrics accurately reflect clinical competence.
A BMJ Open study[1] analysed performance data across multiple postgraduate exams and found that even after adjusting for knowledge and clinical experience, IMGs scored significantly lower than UK-trained candidates. A 2024 British Journal of General Practice paper reported similar patterns for the MRCGP clinical skills assessment.
If clinical knowledge is not the primary differentiator, it is necessary to examine what factors contribute to these disparities.
Language can serve as a proxy for perceived capability. Accent, tone, and phrasing may influence perceptions of confidence or empathy. In high-stakes oral examinations, these nuances can affect outcomes to a greater extent than examiners may recognise.
Assessment is not a neutral process, it reflects the culture of its designers. When those responsible for designing assessments do not represent the diversity of the assessed population, the definition of "merit" may shift toward conformity rather than genuine competence.
True reform means rethinking what we measure, not "How well does this doctor fit our culture?" but, "Can this doctor deliver safe, effective clinical care within the NHS system?"
In practical terms, genuine reform requires that internationally trained doctors are evaluated based on their clinical abilities rather than their assimilation to local norms. Competence should be assessed according to the actual demands of the role, not by the degree to which IMGs conform to existing expectations.
Moving beyond one-off fixes
Numerous NHS organisations have introduced 'mind the gap' initiatives, mentorship networks, cultural awareness courses, and advocacy projects. Professional IMG networks have also established community learning groups and peer support systems. While these interventions can offer benefits, lasting improvements require systemic changes focused on accountability and inclusion. According to a BMJ report, the NHS has recently introduced its first standardised induction programme for international medical graduates, marking an important step toward a more sustainable and supportive approach.
Standardised, funded induction for IMGs. The GMC and several NHS England pilot programmes show that structured local induction within the first three to six months cuts attrition and improves confidence levels.[2]
Equity audits in education and assessment. Regular analysis of progression and pass rates by training background, with oversight at the institutional rather than the individual level.[3]
Rebalanced assessment structure. Shift from oral exams that reward verbal style to structured assessments that test clinical decision making. Use blinded scoring where possible. Train examiners not just to recognise their own bias, but to actively interrupt it, which means calibration with real cases and feedback, not one-off workshops.
Recognition of prior experience. A consultant leading an emergency unit overseas should not have to restart at a foundational clinical level. Reform means establishing equivalency pathways that credit prior clinical training and leadership experience, allowing entry at the appropriate training tier rather than forcing a restart. It means paying for experience, not pretending it does not exist. It means treating an IMG's prior clinical experience as relevant, not as a liability to work around.
Meaningful governance inclusion. This is shared governance with real power, by actively seeking IMG doctors to help design the training standards and assessments they are judged by. This is not consultation, it is co-creation. Using their perspective and experience of what the system actually demanded of them, and what it is missing in the induction and settling phases of migration, is essential in building a progressive healthcare system.
This is not about lowering clinical or learning standards. It is about ensuring that what we measure accurately reflects clinical excellence for every member of staff in your organisation.
What we can change now
Although large-scale reform progresses slowly, targeted local actions can yield a significant impact. Currently, IMGs are assessed by supervisors who determine their clinical competencies. The disparity between necessary systemic change and feasible local interventions defines much of the IMG experience and is often where failures occur. Supervisors and educators who recognise this gap do not wait for top-down reform, instead, they foster supportive environments through structured feedback, recognition of prior experience, and encouragement of professional opportunities. While these measures do not replace structural reform, they are essential for supporting IMGs during transitional periods.
Three proven practices consistently make a difference:
Structured feedback. According to the General Medical Council's Fair Training Pathways review, providing behaviour-based feedback linked to clear assessment criteria can help reduce subjectivity and support better exam performance for internationally trained doctors.
The review also highlights the value of learning from international expertise. IMG colleagues contribute clinical experience from healthcare systems unfamiliar to many UK practitioners. Supervisors who actively seek their perspectives and genuinely listen gain valuable insights, as do their teams. This process extends beyond 'cultural awareness', it acknowledges that clinical experience acquired abroad constitutes genuine expertise.
Active sponsorship, not solely mentoring. While mentoring is valuable, sponsorship involves advocacy, such as recommending individuals for research opportunities and facilitating access to networks where leadership pathways are determined. IMGs frequently demonstrate clinical excellence but may remain excluded from these informal networks. Doctors who receive sponsorship and support are more likely to advance into research and leadership roles, whereas those without such support are less likely to do so, regardless of their competence.
Redefining fairness
Differential attainment is frequently described as a gap, but it is more accurately a lens that reveals the intended beneficiaries of institutional structures. While diversity is often discussed, fairness continues to rely on individuals adapting to existing norms rather than on systems evolving to accommodate diverse backgrounds. Many doctors currently occupying non-training positions were previously leaders in their home countries. Despite their expertise, they must repeatedly demonstrate their readiness. Each instance of burnout or disengagement represents a loss not only for the clinician but also for patient care.
Patients do not benefit from systems that exclude capable clinicians due to unfamiliarity with local practices. Instead, they benefit from workplaces that recognise and value competence, regardless of where it was acquired. Fairness in medicine is not an act of charity, it is essential for building a sustainable workforce. The NHS is dependent on its international workforce. Staffing shortages, clinician burnout, and increased patient wait times are exacerbated when capable doctors leave because the system fails to support them. When institutions embed fairness into assessment, induction, and leadership, they are not acting out of altruism but necessity. Doctors, including IMGs, deserve systems that acknowledge their competencies and facilitate their contributions. This approach is fundamental to building a progressive NHS characterised by effective clinical practice.
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Read more from Dr. Omosefe Christina
Dr. Omosefe Christina, Medical Doctor, CEO and Founder
Dr. Omosefe Christina creates digital learning platforms that turn frontline experience into practical support for international doctors in the UK. She is the CEO of Elite Exams, which supports the medical education of international trained doctors aspiring to become independent GPs. She builds digital systems, courses, platforms, and automated learning pathways to support doctors who migrate to the UK.
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