Challenges for international medical graduates in the US and the UK graduate medical education and health care system environment: A comprehensive review

A comprehensive review of past research and statistical data is necessary to understand the significant obstacles encountered by International Medical Graduates (IMGs) in the healthcare systems of the USA and UK. A careful review of the literature shows that financial, cultural, and linguistic barriers are worsened by the intricate USA licensing processes overseen by the ECFMG. The BMJ and the AAMC's research statistics demonstrate the prevalence of these difficulties and their impact on the career trajectories and well-being of IMGs. The study assesses the impact of professional networks, mentoring programs, and support systems in addressing challenges faced by IMGs in the healthcare sectors of the US and UK, emphasizing the significance of evidence-based interventions in developing inclusion and equality. International Medical Graduates (IMGs) play an important role in graduate medical education and broad medical settings, but their integration present challenges that need thoughtful evaluation of many concerns they face.


Introduction
IMGs play a role in the healthcare systems of both the United States and the United Kingdom.IMGs have problems when they go into graduate medical education and the wider healthcare setting.Roughly 25% of the medical professionals practicing in the United States are graduates of foreign medical schools.Pass rates for International Medical Graduates (IMG) on licensing tests differ, with 65% clearing USMLE Step 1 and 55% passing the PLAB exam in the UK [1].IMGs usually spend around 2-3 years navigating the application process to get residency spots.IMGs from US residency programs have estimated dropout rates ranging from 10% to 15% [2].Approximately 30-40% of IMGs have languagerelated difficulties while talking to patients [3].IMG also encountered costs between $5,000 and $10,000 for visa application fees and $2,000 to $5,000 for residence programme application fees [1].60% of international medical graduates in the United States choose primary care specializations [4].Research shows that as many as 30% of IMGs face prejudice and bias in their jobs.Additionally, 40-50% of IMGs have reported feeling burnout throughout their training.[1].When considering future employment opportunities, IMG often chooses to work in regions that have limited healthcare resources, with 20% of them working in rural or medically underserved areas [5].

Objective
Explores the challenges faced by IMG in the United States and the United Kingdom using findings from previous studies.

Methods
A comprehensive examination of the peer-reviewed literature identified studies that investigated the difficulties encountered by IMG in graduate medical education (GME) and healthcare systems (HCS) environments in the United States and United Kingdom.The chosen studies included both qualitative and quantitative research, focusing specifically on recent publications from the last several years.

My Journey
I was in my faculty office when I first met my wonderful friend and my fellow colleague and my roommate.I was excited to start sharing some of my thoughts with her, while at the same time, trying to overcome the imposter syndrome and feelings of swelling in my chest.But mostly I was sharing feelings with her about working and cultural pattern in the US and UK.This was the first time we had the conversation in our office and decided that I we have to pen all our feelings down.I couldn't help but think how representative this moment was of what it's like to be an International Medical Graduate (IMG) in recent years.I do not claim to represent the voices of all IMGs, but I hope sharing my experience can shed light on some issues and possible solutions.
"Why did you come to the U.S.?" is a common question I was asked.The majority of the time, it's out of genuine curiosity rather than implicit microaggression.At those moments, I ponder -what drives anyone's choices in life?Probably running away from something or toward something else.It's trying to avoid meeting our worst fears or chasing the stars.
A common misconception among the medical community in the U.S. is that IMGs are a monolith.But IMGs come to the U.S. for graduate medical education/jobs for various reasons -looking for a more humane, high-quality, structured graduate medical education experience that leads to a more predictable career path.We're hopeful for a more fulfilling life and career -whatever that may mean to each of us.Some came to the U.S. as a legitimate pathway to immigration.Others are escaping wars, seeking reunification with their loved ones, or fleeing discrimination.We're eager to learn about how the U.S. pushes the limits of science and medicine.
International medical graduates have become a vital part of the US and UK graduate medical education (GME) and health care system (HCS) workforce; they contribute to essential diversity that relieves cultural and linguistic barriers to health care.The number of IMGs looking for medical training in the United States and UK. has constantly been increasing in the last decades.The challenges we meet begin long before job application, continue during their transition to interview programs, through licensing exams, and eventually subside into promotional senior careers.IMGs' hurdles permeate the themes of navigating the US/UK GME and HCS, adaptation to the US/UK culture, communication skills, racial discrimination, emotional distress, and finances.This article aims to comprehensively review available information concerning the challenges encountered by IMGs in their transition to the US and UK GME and HCS environments.

Licensing and Credentialing Processes for IMG
IMGs must complete licensing and credentialing requirements to practice medicine in the United States and the UK.These procedures are intricate regulatory frameworks that evaluate the eligibility and competence of IMG to provide healthcare services within their healthcare systems.
In the United States, IMG must primarily pass the United States Medical Licensing Examination (USMLE) series, which comprises Step 1, Step 2, Clinical Knowledge, and Step 2 Clinical Skills, to get a medical license.IMGs must also get ECFMG certification to certify their medical education credentials.State-specific criteria and rules in the US affect the licensing process, leading to variations in timescales and processes across various jurisdictions [6].
In the United Kingdom, overseas medical graduates must pass the Professional and Linguistic Assessments Board (PLAB) tests [7].The examinations assess their knowledge and clinical abilities.IMGs must pass the PLAB examinations to be able to register with the General Medical Council (GMC) and work as doctors in the UK.The PLAB route is an evaluation approach created to evaluate the competence of IMG based on UK healthcare standards [8].
The differences in licensing examinations, prerequisites, and schedules between the US and UK pose difficulties for international medical graduates as they go through the process of acquiring credentials.USMLE and ECFMG certification assess knowledge and clinical performance, whereas PLAB tests test candidates' adaptability to the UK healthcare system and their English communication abilities.The unique evaluation standards represent the healthcare settings and professional standards present in both nations [9].Barriers to licensing have effects that go beyond the test results.Following the rules.It also changes the paths of IMGs' careers and their ability to fit in with the healthcare system.IMGs can't join residency training courses because their licenses aren't ready yet, which limits their chances of getting experience and moving up in their careers.Also, the complicated licensing requirements may make IMGs feel even more unsure and let down, which creates problems that make it harder for them to fit in with the healthcare industry.
Licensing and credentialing processes affect the career trajectories of graduates in the United States and the United Kingdom.Understanding the complexities of these systems and overcoming the hurdles they present may promote involvement and progress for international medical graduates in the healthcare sector.IMGs may overcome licensing difficulties and contribute to providing high-quality healthcare services in various settings by developing strategies and taking actions [4].

Financial
The Association of American Medical Colleges (AAMC) produced research that emphasized the difficulties encountered by IMG.Visa application expenses might even be thousands of dollars.IMGs have challenges with residency programme costs, including application fees and interview expenditures.This may especially affect those from poor socioeconomic backgrounds [10].
Socioeconomic variables influence the resources available to IMG and their prospects for professional advancement.Research in the British Medical Journal (BMJ) shows that IMGs have disparities in resources, with those from lower socioeconomic origins encountering challenges in funding their medical education.
It's not just money problems that limits have a big effect on IMG's health, job happiness, and career routes.A study in the Journal of Graduate Medical Education found that IMGs who were having problems said they were very stressed, burned out, and unhappy with their jobs.Because they don't have enough money, IMG may not be able to get the training, medical education, guidance, and networking opportunities they need to move up in their jobs.
IMGs' experiences and outcomes in the US and UK healthcare systems are affected by their ability to pay for care and their social and economic background.To deal with these problems properly, we need a plan that looks at the whole picture.This should include creating programs that provide funding the events that support equality and diversity in the medical field.As stated, healthcare stakeholders can help IMGs' professional growth and health in a variety of healthcare situations by getting rid of barriers [10].

Support Systems and Mentorship Programs
International medical graduates depend on support initiatives to facilitate their integration into the healthcare systems of the United States and the United Kingdom.Mentoring and professional networks are crucial components of these support systems.Research indicates that institutions and professional groups that provide mentorship programs promote IMGs by offering advice, assistance, and networking opportunities.Research in the Journal of Graduate Medical Education found that international medical graduates who engaged in mentoring programs reported greater job satisfaction and career advancement compared to those without mentorship [6].
Academic institutions, professional groups, and governmental agencies have distinct responsibilities in providing assistance and advocating for the interests of IMG.In the United States, ECFMG and in the United Kingdom, GMC provide guidelines on licensing, certification, and residency training requirements for IMG [11].Organizations such as the AMA and BMA work actively to promote legislation that meets the needs and challenges encountered by IMGs in healthcare settings [11].
The efficacy of support programs for meeting the requirements of IMGs varies depending on aspects like accessibility, cultural sensitivity, and the quality of mentoring.Studies highlight the need for support systems that recognize the backgrounds and experiences of IMG [12].Healthcare stakeholders may discover ways of assessing the effects of these programs.Develop measures to enhance the assimilation and welfare of IMG in healthcare systems in the United States and the United Kingdom [11].

The Time
For IMG to become doctors in the UK, they have to go through two steps.They need to get a job and sign up with the General Medical Council.In the past, this trip took 8 months and included things like taking and passing the IELTS or PLAB tests [12].Still, the schedules have been greatly pushed back because of delays on the PLAB route [1].There are a lot of doctors who want to take the PLAB tests, so the process from IELTS or OET to PLAB 1 may now take up to a year.In the case of IMG, their PLAB trip could last for 18 months or longer.Candidates could use this time to improve their CVs, which could cut down on the time it takes to get a job or get into a specific training course in the UK.Usually, it takes between one and two years to finish this process and pass all the tests that are needed [12].It might take longer if you prepare well and work hard over and over again [15].

Navigating the Beginning
Doctors who want to work in the UK usually start by getting permission from the General Medical Council (GMC) [13].
No matter which road is chosen, there are steps to take.Either the IELTS or the Occupational English Test (OET) must be taken first to show how well they can speak and write English.They need to pass a test approved by the GMC, like the PLAB, Membership of the Royal Colleges of Physicians (MRCP), Membership of the Royal Colleges of Surgeons (MRCS), or something similar [19].
For the IMG degree to be valid and allow the holder to practice medicine in the UK, it must be approved by the GMC.Depending on their background and area of expertise, foreign doctors may need to send extra paperwork with their application for registration.In addition, students have to meet their financial obligations by paying the GMC fees needed to finish the application process [14].
After acquiring your GMC registration as an IMG, we may start looking for positions on approved NHS recruitment portals.It is advisable to prioritize obtaining GMC registration before initiating employment applications for dependability [1].By following the requirements and acquiring GMC registration, IMG may pursue work possibilities in the UK healthcare system and use their talents and knowledge in patient care [16].
After finding a place to live, many graduates have to go through a tough paperwork process to apply for a J-1 visa as an exchange visitor to the US.Doctors are not the only ones who can get this type of visa.A lot of the time, it lasts a year.The visas are updated every year at the U.S. Embassy in the doctor's home country.As long as the trainers renew their "Certificate of Eligibility for Exchange Visitor" (DS 2019), they can stay in the U.S.They need to update their visa [13] if they want to come back after leaving.
In order to renew their visa, many trainers have to go back to their home country once a year to meet with the government and have an interview with an officer [17].In other countries, visa renewal can be done by mail.Before the crisis, it was hard to plan a holiday while living in the U.S., make sure it didn't conflict with a visa appointment, and get back to the U.S. on time.During the epidemic, these problems were almost impossible to solve because of things like plans at U.S. embassies, travel limits, and other issues [15].If you go to the US for emergency training without making an appointment at the office in your home country first, it could affect your training [1].It's also possible that finishing will take longer than expected, sometimes for days or even weeks [20].

Conclusion
IMGs are important to US and UK graduate medical education and patient treatment.Yet, they encounter obstacles to integration, job progress, and well-being in varied healthcare settings.Careful preparation and networking are needed to apply for US and UK residence or fellowship programs.Staying in touch with family and friends, arranging documentation, and booking trips and visa appointments can help with moving.Self-care, study habits, mentorship, clinical engagement, and ongoing learning must be prioritized by students and residents.IMGs struggle financially due to visa applications, residence programme fees, and other costs.IMGs' socioeconomic backgrounds often limit their finances and job progress, worsening disparities.
Licenses and certifications are tough for IMGs to get, including passing the USMLE and PLAB.These methods assess medical knowledge, clinical skills, national healthcare standards, and professional criteria.This complicates professional advancement and may cause IMGs to feel unsettled and dissatisfied.Cultural and language hurdles, as well as the difficulty of adapting to new healthcare systems, lead to IMG burnout and discontent.For international medical graduates to integrate and succeed professionally, support and mentorship are crucial.Institutions, professional groups, and government agencies should work together to assist IMG and promote diversity and inclusion in healthcare.
All healthcare stakeholders must work together to help IMGs in the US and UK.Implementing evidence-based therapy, campaigning for legislative reforms, and creating supportive settings can help IMGs succeed professionally and improve healthcare quality.Diversity and inclusion will improve IMG and global healthcare.These essentials help medical professionals improve personally and professionally.These ideas help people build resilience, improve their health, and succeed in their jobs.