Professional integration of immigrant medical professionals through alternative career pathways: an Internet scan to synthesize the current landscape

Underutilization and underemployment of skilled immigrants create a significant financial burden on individuals and economic losses for the host country [1, 2]. This is especially true for internationally educated health professionals, including international medical graduates (IMGs), who gained their qualifications from a medical school in a country other than the one in which they seek to professionally integrate [3, 4]. These professionals are also referred to as foreign medical graduates (FMGs), overseas trained graduates (OTGs), internationally trained physicians (ITPs), or internationally educated physicians (IEPs) [3]. They are particularly vulnerable within the host country’s labour market, as many IMGs fail to be recertified and employed in their original profession [5]. For example, in the United States, about half of the IMG candidates who applied to a residency programme were denied a position [6], and in Canada, about 80% of the IMGs who applied could not enter residency programmes in 2019 [7‐9].

Against this backdrop, IMGs are often forced to look for alternative careers in order to secure their livelihood. There is no established alternative career definition for IMGs, however, or this study, we have defined alternative careers for IMGs as those non-physician health and wellness jobs where the health-related knowledge and skills of IMGs can be utilized. Some IMGs choose alternative careers so they can earn a decent living and support their family while pursuing licensure [10]. For those who decide not to pursue medical licensure and give up obtaining their licence as a practising physician, the alternative career becomes their new goal. Commencing alternative career pathways (ACPs) related to health and wellness may boost IMGs’ prospects of better integration into the labour market by increasing opportunities for them to employ their transferable skills and experience [11, 12], and thereby earn a dependable living and contribute to the host country’s economy.

There has been a reasonable amount of work undertaken regarding IMGs’ professional integration as a physician in their host countries [13‐15], but the work on ACPs has been scarce. Moreover, there are many organizations that provide support and information to the IMGs (such as AIMGA, HealthForceOntario, etc.) primarily on becoming licensed physicians in Canada. But the information and resources for issues related to alternative career pathways for the IMGs in Canada, who have not been certified as physicians, is scarce [16]. Some individual efforts have been noticed on the news and other media at a personal or organizational level [17], however, no knowledge synthesis is available informing what initiatives exist altogether and how they facilitate the integration of IMGs through alternative careers. A comprehensive understanding of what alternative paths are available for the professional integration of IMGs, what information resources and capacity-building initiatives are in place, and if any, how they work is quite important. While there is scarce information in the refereed journals [16], we assumed that there might be some programmes and initiatives on a smaller scale and at individual levels that might be available on the non-academic information sources. To make an evidence-informed step ahead in this previously less explored area, we need all the information that we can avail. Therefore, we have conducted this Internet scan (I-scan) with the objective of identifying the available individual, private, and systemic initiatives and resources that support these health professionals in their pursuit of alternative careers. Having this information will allow different levels of stakeholders of this matter the preliminary knowledge to take solution-oriented research and programme initiatives.

Through our I-scan we identified the websites of the information and capacity-building resources and extracted the supports available for the IMGs’ pursuit of alternative careers. We found that most of the supports are non-specific to IMGs and rather focused on general employment-related supports such as language training, job search, and Canadian work environment-related information and training. We have only found one bridging programme that specifically supports and provides training to IMGs for building their capacity for certain alternative careers. However, many possible alternative jobs were mentioned and information regarding how to avail those careers was described to some extent. Therefore, we attempted to extract the alternative careers and the transferable skills and put them into certain categories that will help cluster the jobs requiring similar transferable skills and help IMGs and their stakeholders take action to their capacity accordingly. A range of transferable skills including essential skills such as administrative and leadership, and specific health-related technical knowledge and expertise such as knowledge of medical terminology was mentioned in the webpages. Identifying and nurturing those can help target relevant jobs and employ these valuable skills and improve professional integration.

Our search did not reveal extensive resources and initiatives to bolster IMGs’ pursuit of job market integration through alternative paths outside of the physician profession. Possible explanations for the limited information could be the concept of employing unlicensed IMGs into health and wellness through alternative careers is relatively novel. Moreover, IMGs come to this country with the dream of becoming a practising physician and spent most of their time and energy in the pursuit of physician licensure. Unfortunately, when many of them fail in the pursuit of their long-cherished dream after years of endeavour, only then they think about alternative career. But at that moment they do not have enough time and energy, and often burdened with financial and family responsibilities that hinder them to give more efforts for decent alternative career pursuit [7, 8, 40, 41]. We did not put any country or region restriction in our search, however, we noticed that available information sources are geographically condensed in Canada followed by the United States. This probably reflects the fact that despite being popular destinations for IMGs, the success rate for integrating as a physician Canada (15–30%) is much lower than the other common IMG destinations in the world such as the USA, the UK and Australia (50–80%) [34, 37, 40‐44] The Canada-centricity of the findings of our search indicates that Canada is the most unfavourable host country for integrating IMGs as a physician and requires systematic and strong support the most for the IMGs in their alternative career pursuit.

There is a lack of comprehensive information about the processes IMGs go through when searching for work and the factors that influence their career decisions. Exploring the hiring process from the perspective of employers would deepen our understanding of their decisions with regard to hiring IMGs [45]. Additional research is also needed to develop evidence-based strategies to support IMGs with their career choice process [7, 8]. A decision support tool might prove helpful for IMGs in their efforts to find and pursue an alternative career where they can use their existing skills [40, 41]. We also could not find any indication that cultural backgrounds, any suitable previous training for alternative careers, socioeconomic constraints in the new country, or other factors have been considered when working on ACPs for IMGs. Furthermore, it seems the IMG population has been considered a single homogeneous population, but in reality, it is very heterogeneous [46]. The heterogeneity factor needs to be incorporated in our understanding in this area.

Despite being a non-conventional approach to knowledge synthesis this I-scan study has several strengths. To extract the non-academic information, which follows no structured organization of knowledge repositories and databases, we have used a methodologically sound and transparent process to identify and map the information. We have gathered a team of researchers with expertise in the study area and knowledge syntheses methodologies who designed and conducted the study. We have also engaged stakeholders and citizen researchers’ from IMGs and IMG serving organizations to validate and contextualize the data, and their contributions throughout the project made the findings applicable and highly relevant to stakeholders and knowledge users.

Notwithstanding the strengths, some limitations need to be recognized. Given the complexity and breadth of definitions for ACPs, our search terms may have resulted in missing certain web pages. Also, despite using the incognito mode of the browsers to carefully avoid the reviewers’ location and personal web activity history influencing the search results, it cannot be guaranteed that the search results were not absolutely influenced by the IP (Internet Protocol) address of the search. This could have skewed the origin country of the majority of the identified websites in this study to Canada. However, we argue that our flexible approach to search terms ensured a reasonable breadth of relevant web page identification. Another limitation is that our search was restricted to the English language. Thus, our findings may not be generalizable to non-English speaking countries, e.g., in Germany, where more and more IMGs immigrate to fill the need for physicians, and in 2016 IMGs constituted 11% of the German medical workforce, with the majority coming from Southeastern Europe and Syria [47].

In conclusion, this study serves as an initial step towards establishing a practical knowledge base for identifying research and development gap including strategic support and programmes for facilitating IMGs’ pursuit of alternative careers. Our study indicates that there is only a handful of information resources and support initiatives available for IMGs’ pursuit of alternative career. Moreover, despite IMGs more or less struggle to pursue their primary career choice, i.e. becoming a licensed physician in many countries, the information and support regarding that were more limited to Canada. This could be made more common to the USA, the UK, and other countries. Therefore, more systemic policies and IMG specific and ACP-focused employment support programmes are needed to be built. Our findings can help IMGs, stakeholders, and policy decision-makers make more informed personal and policy decisions.