An international medical graduate (IMG) is a medical doctor who has obtained their primary medical qualification from a medical school outside of the country where he or she intends to practise. A clinical attachment is an unpaid placement opportunity involving shadowing a colleague in a relevant specialty to learn from their clinical practice. It does not involve responsibility or clinical decision-making, but is intended to give doctors exposure in their chosen specialty.1 Recruitment and retention of doctors in psychiatry has been a long-standing challenge. In 2019, almost 10% of consultant psychiatrist posts in English National Health Service (NHS) trusts were unfilled – around twice the proportion recorded in 2013.2 There are significant threats to retaining existing doctors, particularly groups such as IMGs.3
In 2019, more doctors joining the UK workforce were IMGs compared with UK-trained. It is crucial that these doctors are well supported to accept new roles and work within effective clinical governance systems. However, IMGs are much more likely to leave the medical workforce. Between 2012 and 2014, 3% of UK-trained doctors left the NHS, compared with 6% of IMGs.3
IMGs face numerous challenges when first arriving to work in the UK. These doctors have been found to be less likely to understand the regulatory framework of working within the NHS with regard to the ethical, legal and cultural differences in the UK compared with their country of training.Reference Slowther, Lewando Hundt, Purkis and Taylor4 Furthermore, clinical practice can vary greatly between countries, with adjustments required to many aspects of work, including altered team structures and communication skills.Reference Jalal, Bardhan, Sanders and Illing5 These barriers may act as deterrents for IMGs to take up work opportunities in the NHS.
A study analysing the clinical attachment experiences of 573 IMGs in North East England reported that 90% found their attachment useful, with over half (57%) reporting that they would not take up an NHS post without a clinical attachment first.Reference Wawdhane, Saraf, Davidson and Trewby6 Hence, clinical attachment posts can be an important tool to enhance recruitment and retention of IMGs.
This study aims to explore whether clinical attachments in psychiatry could aid recruitment of doctors to mental health services.
Method
Questionnaire development
An online survey questionnaire using Google Forms was designed to obtain the relevant data for the study. Two researchers working independently developed the initial questionnaire items. Questionnaire items were discussed for relevance and clarity prior to confirmation of the final questionnaire tool. Data on respondents’ gender, age group, country of origin and previous psychiatry experience were collected to better understand the demographics of individuals considering moving to work in the UK. The subsequent section of the questionnaire used Likert ratings to ascertain degree of interest in a clinical attachment in psychiatry, belief that an attachment would enhance career progression and likelihood of accepting a job at the same NHS trust. The questionnaire also included a multiple choice question to ascertain ideal length of a clinical attachment. A free-text box was included to offer respondents a section to make comments regarding their thoughts on organising a clinical attachment and intended benefits of completing a clinical attachment. The final questionnaire included an option to enter an email address to be contacted with further information about clinical attachment opportunities – this was intended to support future studies.
Prior to distribution, the questionnaire link was piloted with a small group of junior doctors to ascertain ease of use and clarity of the question wording. The wording of some questions was altered in response to feedback. The opening section of the questionnaire link also included a definition of clinical attachment and a summary of the questionnaire aims.
Questionnaire distribution and data collection
The finalised questionnaire (Supplementary Appendix A, available at https://dx.doi.org/10.1192/bjb.2023.59) was posted on a popular closed Facebook group of IMG doctors interested in obtaining the MRCPsych qualification. The administrator of the group was approached to obtain consent to post the questionnaire information. Sampling was purposive, as group members were likely to use clinical attachments to introduce them to the NHS. The sample size was pragmatic, based on the number of survey responses over an 8-week period between August 2020 and October 2020.
The questionnaire was posted on the group page with a message to summarise the project and its aims. This post was repeated twice during the data collection period, to capture any members who had previously missed the post or were new to the group. The members submitted responses anonymously. The optional email address input was separated from responses prior to analysis and no other person-identifiable data were obtained.
Analysis
Data collected from the questionnaire were imported to an Excel spreadsheet. Demographic information was analysed and presented using frequency tables and bar charts. Responses to questions rated on a Likert scale were presented using bar charts. The percentage of each response was calculated. Analysis of questionnaire responses was conducted on Microsoft Excel 2016.
A qualitative analysis of the free-text box responses was performed. The free-text responses were transferred to an Excel spreadsheet.
Thematic analysis was conducted on the collected qualitative data. Themes were defined using an inductive approach, arising from ideas that emerged from the free-text responses. Themes were defined by two researchers working independently, with comparison and discussion to define the final themes.
Ethics
The study team completed the Health Research Authority algorithm, which determined that the study was not considered research and therefore did not require NHS Research Ethics Committee review (Supplementary Appendix B). Completion of the questionnaire was considered implied consent for respondents’ anonymous data to be analysed and presented.
Results
A total of 92 responses were received between August 2020 and October 2020.
Respondent demographics
The respondent gender split was 46 males (50%) and 46 females (50%). The most common age group was 25–34 years (65.2%). The frequency for each age group is displayed in Table 1.
Table 1 Age group distribution (n = 92)
The most common country of origin was India (45.7%), followed by Pakistan (18.5%) and Egypt (10.9%). The distribution of country of origin is displayed in Table 2.
Table 2 Distribution of respondents’ (n = 92) country of origin
Previous experience in psychiatry
Almost two-thirds of respondents (n = 57) had 3 or more years’ experience in psychiatry; just under a quarter (n = 21) had 0–1 year's experience in the area. The distribution of experience is displayed in Table 3.
Table 3 Respondents’ (n = 92) experience in psychiatry
Responses to Likert-scale questions
Overall, 78 respondents (84.8%) rated 5 (strongly agree) that they would be interested in a UK psychiatry clinical attachment; only 1 respondent rated their interest as 1 (strongly disagree). Responses are represented as a bar chart in Fig. 1.
Fig. 1 Distribution of responses (n = 92) to the question ‘I would be interested in taking up a clinical attachment in psychiatry in the UK’.
In response to the statement ‘I feel that a clinical attachment will support my career progression in psychiatry’, 79 respondents (85.9%) responded 5 (strongly agree); 11 (12.0%) responded 4; 1 responded 3; and 1 responded 1 (strongly disagree).
In response to the statement ‘If offered, I would accept a job in the same NHS trust following my clinical attachment’, 67 respondents (72.8%) responded 5 (strongly agree); 20 (21.7%) responded 4; 4 responded 3; and 1 responded 1 (strongly disagree).
Preferred duration of clinical attachment
The most commonly preferred duration of the clinical attachment was 4–8 weeks, chosen by 47 respondents (51.1%). More than 8 weeks was the next most commonly preferred duration, chosen by 29 respondents (31.5%). The distribution of responses is presented in Fig. 2. Further figures are viewable in Supplementary Appendix C.
Fig. 2 Distribution of responses (n = 92) regarding preferred duration of a clinical attachment in psychiatry.
Qualitative analysis
Theme 1: IMGs’ aims from a clinical attachment in psychiatry
IMGs aimed to achieve a holistic experience from a clinical attachment, beyond purely clinical experience or shadowing/observing opportunities.
A range of clinical aims were identified from the free-text comments section. IMGs aimed to gain clinical experience in core psychiatric subspecialties in a range of different settings, including out-patient services, in-patient services, crisis and emergency response teams and psychotherapy:
‘[I would like to gain] proper clinical exposure to psychiatric outpatients and inpatients, including psychiatric emergencies’ (Respondent no. 12).
Furthermore, a common aim included understanding the functioning of the NHS, including local policies, procedures, guidance, guidelines and management of services:
‘I would wish to understand more about management guidelines in the UK [and] be orientated with latest drug and psychotherapy updates’ (Respondent no. 5).
Finally, gaining insight into the cultural aspects of psychiatric practice in the UK and its impact on clinical decisions was a valued aim for the responding IMGs.
Non-clinical aims were also outlined in the free-text comments section, including experiencing life in the UK and acquiring details of further training and work opportunities. IMGs expressed interest in having a platform to network with other IMGs at different stages of their medical career to benefit from shared learning opportunities. This was reiterated in the form of shared preparation for MRCPsych clinical assessment of skills and competencies (CASC) exams:
‘It is great to have a network that connects different areas and […] a list of possible candidates [other IMGs]’ (Respondent no. 9).
Theme 2: benefits of a clinical attachment for IMGs
Respondents noted that a clinical attachment would be a crucial step for IMGs like themselves at various stages of their training to start their medical career in psychiatry in the UK and that it could enhance their confidence in applying for jobs in psychiatry.
Benefits to IMGs with no previous experience in psychiatry included initiation of job opportunities in psychiatry following their completion of part two of the Professional and Linguistic Assessments Board test (PLAB 2) and obtaining a General Medical Council (GMC) registration to practise. Respondents highlighted that an attachment would also make starting their first job in the NHS easier and less stressful:
‘A clinical attachment would help me gain experience in psychiatry and would make my first NHS job a lot easier’ (Respondent no. 21).
For IMGs with previous clinical experience and training in psychiatry, benefits outlined included psychiatrists qualified from low- and middle-income countries (LMICs) being more confident in applying for jobs and starting work in the NHS. Respondents thought an attachment would benefit IMGs starting on the Royal College of Psychiatrists’ (RCPsych's) Medical Training Initiative (MTI) scheme and should be offered routinely to everyone starting on this scheme:
‘Attachment should be a part of Royal College of Psychiatrists sponsored MTI scheme allowing foreign psychiatry specialists to obtain GMC registration in the UK’ (Respondent no. 17).
Respondents also outlined that their learning from the attachment would be a key to becoming a good psychiatrist offering high-quality psychiatric care, with some pointing out that psychiatrists from LMICs can disseminate and implement their learning to improve mental healthcare in their home nations.
Theme 3: IMGs’ needs when applying for a clinical attachment
Respondents expressed their thoughts on the application process for clinical attachments. They noted that a clear, simple and straightforward process is needed to apply for these posts, and guidance on completing the application process was much valued:
‘[I would like] clear guidelines on the application process’ (Respondent no. 2).
Respondents mentioned the idea of an information leaflet describing roles, responsibilities and details of the post as being potentially helpful for IMGs. Further information regarding accommodation, travel and visa process was discussed in the free-text responses:
‘[I] need a residence to live in with a family’ (Respondent no. 11).
Discussion
Considering the demographics of the respondents, all were aged under 55, although the medical workforce in the UK includes around 1 in 4 workers aged over 55. This may be due to the method of survey distribution on online platforms, where older users tend to be less active.Reference Ortiz-Ospina7 Although this survey included equal numbers of men and women, the medical workforce is in fact 57% male to 43% female.8 In terms of country of qualification, the majority of respondents obtained their primary medical qualification in Asia, which is similarly seen in the origin of IMGs working in the UK across all medical specialties.9 Overall, the survey respondents varied in demographics enough to give a representation of views of various members of the workforce. Further information about the demographics of IMGs within the UK medical workforce may help to determine the representativeness of the sample in comparison to IMGs in the UK.
Respondents expressed interest in a UK-based psychiatry clinical attachment and believed it would support their career progression. This supports the notion that clinical attachments could be a suitable method to enhance recruitment within the psychiatry medical workforce. Most respondents expressed that they would accept a role at the same trust as their attachment if offered. This finding offers considerable incentive for trusts looking to fill substantiative posts to organise and run clinical attachment programmes with a view that this investment could support long-term recruitment. The most popular duration for the clinical attachment was 4–8 weeks. Knowing the preferred duration of attachment can guide trusts in organising attachments that support IMGs in maximising their benefit from the role.
Previous studies have not considered IMG views on NHS psychiatry clinical attachments, so judging whether interest in clinical attachments has changed over time is difficult. Understanding interest in clinical attachments can help guide NHS trusts in designing time- and cost-effective methods to support recruitment.
The first theme found that IMGs wish to find out more about clinical and non-clinical aspects of working in the UK. The importance of non-clinical aspects affecting IMG migration is supported by Jalal et al, who found that key barriers for IMGs migrating to work in the UK included workplace culture and communication.Reference Jalal, Bardhan, Sanders and Illing5 An understanding of what IMGs aim to gain from a clinical attachment can help NHS trusts design programmes that address the aims. Increased satisfaction from clinical attachments may result in IMGs being more likely to take up substantiative posts within their chosen trust.
The second theme explored benefits to the IMG from a clinical attachment. Respondents felt that the attachment would allow development of relevant skills and enhance confidence in applying for full-time posts. A report by the RCPsych also recognises benefits in terms of preparing for professional exams, building relevant skills and reflection opportunities, supporting views expressed by respondents of our survey.Reference Dave, Al-Uzri, Andlauer, Dias, Maitra and Sivakumar10 The benefits of clinical attachments as elicited in the RCPsych report are similar to those perceived by our respondents. This suggests that the benefits of clinical attachments are appreciated by those taking part and that IMGs are likely to be successful in attaining the benefits intended when they are organised. Alternative methods to deliver similar benefits, such as inductions, have been explored but have been found to be less commonly used than clinical attachments.Reference Wawdhane, Saraf, Davidson and Trewby6
The third theme explored what IMGs need when organising a clinical attachment. Respondents wanted a clear, straightforward application process with guidance on making a successful application.
A study by White et al in 2018 considered the challenges of a formalised clinical attachment programme. One challenge was that some IMG doctors left clinical attachment schemes early on securing a paid role elsewhere – thus not utilising the scheme optimally.Reference White, Malik and Bagalkote11 In our survey, 71% of respondents strongly agreed that they would accept a paid role in the same trust if offered one at the end of their attachment. Although there is still the possibility that they might leave an attachment early, this response suggests that if clinical attachments are formally organised with a view to recruiting longer term, then IMG doctors could be retained by the likelihood of being offered a permanent role following successful completion of the clinical attachment. Another challenge is that attachments involve both medical and non-medical staff in increased administration. Consultants may be unable to take on the supervision of clinical attachés, given their evergrowing workload and responsibilities. There may also be limitations due to lack of existing frameworks for short-term honorary contracts for clinical attachés. Moreover, pre-work checks, such as with the Disclosure and Barring Service (DBS), that are routinely carried out for healthcare staff may be more challenging to accurately complete for IMGs.
Implications and recommendations
This study aimed to explore whether clinical attachments in psychiatry could aid recruitment of doctors to mental health services and explore thoughts and aspirations of IMGs when taking up clinical attachment posts.
Although the study findings clearly show that there is value in clinical attachments to aid recruitment of doctors to mental health services, further research might look at how a clinical attachment could be formally organised to support IMGs and subsequent recruitment in the most effective way. Theme 3, exploring IMGs’ needs when applying for clinical attachments, particularly identified the importance to IMGs of a clear application process. Part of a formally organised clinical attachment can also address theme 1, wherein specific needs of IMGs are addressed, including non-clinical aspects of work. A study by Webb et al in 2014 looking into organising a formal clinical attachment suggests that educational supervisors and peer mentoring during the attachment can be an effective way to support IMGs in their transition to NHS practice.Reference Webb, Marciniak, Cabral, Brum and Rajani12
The Medical Training Initiative (MTI) is an existing scheme supporting IMGs in training and developing their skills through undertaking fixed periods of training within the NHS. This initiative is mutually beneficial in offering trusts skilled doctors to fill vacant training posts for short-term periods. Clinical attachments could play a beneficial role within this initiative as a built-in shadowing period for doctors new to the NHS. Although this study found that 4–8 weeks was the most popular duration for a clinical attachment, the period of this attachment if built into the MTI may need careful consideration to balance exposure to the specialty with the important purpose of the MTI in filling training posts to improve service provision. However, the MTI is a short-term offering for a long-term shortage within the medical workforce.
Further research could also consider not only recruitment of doctors but also retention, which is another important aspect for a sustainable medical workforce.9 IMGs remaining in the NHS for a longer period might undertake psychiatry core training. This component of medical training involves rotational exposure to various subspecialties in psychiatry, which are experienced in significant depth over a period of several years. In contrast, shorter clinical attachment programmes offer a snapshot of the range of experiences and whether they truly offer a taster in enough specialties may be debated. However, if this small snapshot sparks interest and contributes to individuals taking the leap and applying for core psychiatry training, then this may be a worthy investment for trusts to address workforce challenges in both the short and long term.
This study found that if offered a substantiative post in the same NHS trust following a clinical attachment, 71% of respondents would accept it. This implies that clinical attachments could be a suitable method of addressing the recruitment gap in psychiatry. However, barriers were identified, particularly in the process of applying for clinical attachments.
With consideration to the barriers and challenges to organising clinical attachments, further research might explore projected costs and time commitments in organising a sustainable, formal clinical attachment programme. Part of this work could involve addressing the challenges, such as by including supervision of clinical attachés in consultant contracts and job plans. Alongside this, human resources departments of NHS trusts could develop clinical attachment pathways, create honorary job contract templates and carry out appropriate background checks on IMGs to help mitigate some potential barriers in organising clinical attachments.
Development of a streamlined, formalised process with adequate information for interested IMGs could significantly help them in their search for clinical attachments and, subsequently, NHS jobs. Formalised processes could involve website advertisements and clear standardised application processes for attachments throughout the country. Funding would support the development of attachment programmes that truly address the varied needs of IMGs through an exciting taster period. In the long term, this could function as an investment for NHS trusts, which could build a reliable form of doctor recruitment through completion of their formal clinical attachment programmes, enhancing long-term recruitment statistics and patient care. Alternatively, the consideration could be made as to whether individuals seeking such experiences would be willing and able to pay for a high-quality, NHS-endorsed period of exposure to their chosen specialty.
Ascertaining the views of trust clinicians, trainers and managers as important stakeholders can help to show whether there is an appetite for and belief in innovative solutions to address the medical workforce shortage. This will require further mixed-method studies via surveys, interviews or focus groups.
Strengths and limitations
This study is unique in that there have been few recent studies that have collected qualitative data directly from doctors working abroad who are interested in moving to work in the UK. This allows understanding of the wants and needs of an IMG when considering transition to UK practice, particularly relating to the organisation of clinical attachments.
This study is limited by the modest sample size, which is unlikely to accurately represent all IMG doctors who may be targets of clinical attachments. A particular demographic group that is poorly represented in this study is the over-55s, as no respondents reported being aged over 55 although a quarter of the medical workforce in the UK is over 55 years of age. The findings of this study are restricted in their generalisability as the sample is limited to a specific group of doctors with the specific agenda of completing the MRCPsych examinations. With the respondents being primarily from Asia, most commonly from India, this study's findings are limited in their generalisability across IMGs. Further research could aim to capture a larger sample with a broader geographical reach to enhance generalisability. Although the survey was posted on a closed social media group, it is not possible to identify with certainty that respondents’ demographics were as they claimed them to be.
About the authors
Milap Rajpara is a Foundation Year 1 (FY1) doctor with University Hospitals of Leicester NHS Trust, Leicester, UK. Parveen Chand is a consultant child and adolescent psychiatrist with Nottinghamshire Healthcare NHS Foundation Trust, Nottingham, UK. Pallab Majumder is a consultant psychiatrist with Nottinghamshire Healthcare NHS Foundation Trust, Nottingham, and an honorary associate professor in the Department of Psychiatry at the University of Nottingham, Nottingham, UK.
Supplementary material
Supplementary material is available online at https://doi.org/10.1192/bjb.2023.59.
Data availability
Data are available on reasonable request from the corresponding author, M.R.
Author contributions
P.C. conceived the idea for this study. M.R. and P.C. designed the study and conducted data collection and analysis. The manuscript was written by M.R. with supervision and guidance from P.C. and P.M. Supervised by P.M., all authors contributed to manuscript revision and read and approved the final submission.
Funding
This study received no specific grant from any funding agency, commercial or not-for-profit sectors.
Declaration of interest
None.
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