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An opportunity to be grateful for? Exploring discourses about international medical graduates from India and Pakistan to the UK between 1960 and 1980
  1. Zakia Arfeen1,
  2. Brett Diaz2,
  3. Cynthia Ruth Whitehead2,3,
  4. Mohammed Ahmed Rashid1
  1. 1UCL, London, UK
  2. 2The Wilson Centre, Toronto, Ontario, Canada
  3. 3Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
  1. Correspondence to Dr Zakia Arfeen; z.arfeen{at}ucl.ac.uk

Abstract

Introduction Following India and Pakistan gaining independence from British colonial rule, many doctors from these countries migrated to the UK and supported its fledgling National Health Service (NHS). Although this contribution is now widely celebrated, these doctors often faced hardship and hostility at the time and continue to face discrimination and racism in UK medical education. This study sought to examine discursive framings about Indian and Pakistani International Medical Graduates (IPIMGs) in the early period of their migration to the UK, between 1960 and 1980.

Methods We assembled a textual archive of publications relating to IPIMGs in the UK during this time period in The BMJ. We employed critical discourse analysis to examine knowledge and power relations in these texts, drawing on postcolonialism through the contrapuntal approach developed by Edward Said.

Results The dominant discourse in this archive was one of opportunity. This included the opportunity for training, which was not available to IPIMGs in an equitable way, the missed opportunity to frame IPIMGs as saviours of the NHS rather than ‘cheap labour’, and the opportunity these doctors were framed to be held by being in the ‘superior’ British system, for which they should be grateful. Notably, there was also an opportunity to oppose, as IPIMGs challenged notions of incompetence directed at them.

Conclusion As IPIMGs in the UK continue to face discrimination, we shed light on how their cultural positioning has been historically founded and engrained in the imagination of the British medical profession by examining discursive trends to uncover historical tensions and contradictions.

  • Global Health
  • Other study design
  • Health education and promotion

Data availability statement

Data are available on reasonable request.

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WHAT IS ALREADY KNOWN ON THIS TOPIC

  • It is widely acknowledged that Indian and Pakistani International Medical Graduates contributed significantly to the development and running of the UK National Health Service but have historically faced challenges such as racism and discrimination.

WHAT THIS STUDY ADDS

  • This study analysed discursive framings about these doctors in the UK in the BMJ between 1960 and 1980 using a critical discourse analysis. It uncovered attitudes and discourses such as apparent opportunities provided to these doctors, missed opportunities to recognise their value and opportunities for some resistance against stereotypes which may have endured in some current contexts.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

  • This study uncovers the historical tensions and contradictions of Indian and Pakistani doctors in the UK National Health Service and can guide efforts to promote more equitable current policies for and address discrimination against, international medical graduates.

Introduction

A small window of opportunity was created through economic hardship and societal contemplation at the end of the Second World War which led to the establishment of the UK National Health Service (NHS) in 1948. Described as the ‘biggest single experiment in social services that the world has ever seen undertaken’,1 the NHS faced a critical challenge in attending to medical recruitment shortages in the years that followed. To address this existential threat, the resulting migration of international medical graduates (IMGs) predominantly from South Asian countries, such as India and Pakistan, was integral to the expansion of the NHS.2 These doctors played a vital role in both the realisation and consolidation of the NHS particularly in junior posts and in unpopular specialties and geographical locations.2 In 1966, doctors described as ‘foreign-born’ formed one-fifth of all doctors and of these 44% came from the Indian subcontinent which was India, Pakistan and Sri Lanka3 with India and Pakistan forming the larger majority. Much of the literature relates to those from India and Pakistan and for the purpose of this paper, the focus is on Indian and Pakistani International Medical Graduates (IPIMGs).

Medicine in India and Pakistan had been fundamentally shaped by its imperial past and this played a role in creating a pool of qualified and skilled doctors who were well suited to contribute to the NHS expansion.2 South Asian doctors’ reasons for immigration were numerous. The British colonial links to many countries provided a direct pathway. Some pursued personal opportunities for growth in skill development and career progression offered by Britain.4 Some were advised by trainers who had themselves taught in English and often been trained abroad.2 Although there were numerous personal and economic benefits to migrating for doctors, these movements were not without difficulties. Many of these doctors faced ‘open racism and discrimination often leading to repetitive failures in examinations and stunted career progression’.5 They also often filled less popular specialities such as geriatrics, so much so that by 1974 IMGs filled 60% of registrar geriatric posts.6 Moreover, these doctors tended to work in the North-West of England and Wales in non-teaching hospitals where competition to secure posts was perceived to be less.7 8 First-hand reports by South Asian doctors from India and Pakistan such as Menon9 highlighted the regular occurrences of racism experienced during clinical work, and how there was often a lack of appropriate educational support and supervision.

This Westward migration had implications not only for doctors but profoundly impacted the countries from which they migrated. Zaidi10 suggested that in underdeveloped countries, particularly in postcolonial eras, Western influences led to the creation of health structures that centred on curative-type medicine similar to the West and that doctors played a central role. He argued that doctors produced through these systems were indoctrinated to favour the West, preferred by the elite in society and were poorly equipped to treat the greater populace such as in the rural areas of Pakistan. Likewise, Banerji11 examined the historical development of medical and health services in India and described how ‘formation of the health services in colonised countries was subservient to the overall imperial policy of exploitation, expropriation and plunder of these countries to promote economic growth of the colonial powers’. He stated that health services were used as ‘a powerful weapon for the perpetuation of colonial rule’.11

There is now a more widespread recognition that the existence of the NHS was historically dependent on the migration of doctors. However, less recognised is that dependence was matched by discrimination and colonialist attitudes.12–14 In response, many South Asian doctors openly depict their own accounts of migrating to the UK and building a career for themselves in an attempt to raise awareness,15 16 and public exhibitions celebrate the contributions that migrant IMGs have made and continue to make.17

Despite these positive efforts, racism within the NHS remains a continued source of injustice and inequity in contemporary medical education. Looking more broadly at all IMGs within the UK, India and Pakistan were the top two countries for all IMG joiners in 202118 and there are currently 34 469 from India and 21 280 from Pakistan making a total of 55 749 as of March 2024 out of 379 316 doctors as the register (14.7%) and 128 393 IMGs (43.4%).19 A study highlighted how IMGs face additional difficulties in training that impact learning and performance such as negative bias in relationships with senior doctors.20 This importantly links discrimination against IMGs with impact on medical education. Additionally, IMGs are more likely to have lower scores in examinations21 22 and are three times more likely to be referred to the General Medical Council (GMC) for fitness to practice concerns than UK doctors. These issues are not limited to the UK and comparable narratives are mirrored in other Western countries such as the USA and Canada.23 24

The medical community often turns to medical journals as a source of medical knowledge, practice and opinion highlighting the platform they provide to current discourses, although in more recent times, social media and the use of twitter, blogs and online forums have also been used as sources of information and platforms for professional discourse.25 However, The British Medical Journal (BMJ) is one of the world’s oldest general medical journals, first being published in 1840. As a journal that ranks fourth in the world among the top general medical journals and with a potential reach of 9.8 million, The BMJ has widely been recognised as an important and impactful voice for medical professionals,26 especially in times prior to the existence of social media and so the language used in it and engages with its readers is important.

As the foregoing discussion laid out, the NHS has historically grappled with structural racism and attainment inequities facing IMGs. Despite the growing recognition of these issues and exploration of meaningful solutions, there has been little empirical examination of the historical roots and attitudes that may have shaped these inequities in modern medical educational and professional practice. We chose to examine this specific period through historical documents that were situated in the geopolitical events, power relations and postcolonial dynamics that shaped the NHS. To do so, we undertook a critical discourse analysis (CDA) to examine the language used by, and about, IPIMG new to the NHS in the period between 1960 and 1980 as documented in the archive of The BMJ, a popular medical journal for the British medical profession through this time period. The central research question driving this study was as follows: What were the dominant discourses that framed the early period of migration of IPIMG to the UK NHS and What do these discursive framings reveal about beliefs about these doctors?

Methods

CDA and theoretical approach

In medical education research, there is a constant evolution in our understanding of the world around us and one crucial aspect of this involves challenging the established norms and questioning the underlying reasons for their existence. As discourse relates to language, texts and the contexts in which they are used,27 the examination of discourse can be characterised as ‘critical’ when further investigation is conducted to understand the interconnection between ‘power’ and ‘status’,28 especially in relation to historical processes and events. As such, working from a constructivist research orientation and employing a CDA is a particularly appropriate methodological approach here as our research question is concerned with the shaping of people’s knowledge of the social realm and creation of meaning through language.29

There are multiple approaches that can be taken when conducting a CDA.30 Fairclough31 takes a critical approach focusing on the relationship between power and language within the social context. Similarly, Wodak’s32 discourse—historical approach situates discourse as a social practice within historical and sociopolitical contexts. Van Dijk’s33 sociocognitive approach relates macrolevel notions such as group dominance with microlevel notions such as text and meaning. The work of Edward Said provides a particularly relevant theoretical framework to this study. His examination of the discourses surrounding knowledge, power and imperialism revolved around his central topic; Orientalism.34 This work uncovered a discourse that is rooted in the dichotomy between the Western ‘us’ and the Oriental ‘them’ where the Orient is often portrayed as passive, inferior and historically dominated by Western perspectives.35 This approach becomes particularly well suited given the historical context of this study, IPIMGs were arriving in a country that had been in imperial control of their nations for centuries before. Furthermore, Said’s ‘contrapuntal’ reading is particularly significant in this context as it moves beyond the superficial understanding of a text.36 It involves a simultaneous awareness of the historical context in which the text was written, the opposing viewpoints it engages, and its unintended consequences.37 Said’s approach is particularly useful in questioning embedded assumptions and offers a critical lens to analyse power dynamics and prevailing western perspectives within the realm of medical education.

Selection and review of papers

We sought to identify relevant articles published in The BMJ between 1960 and 1980 that were related to IPIMG working in the UK. The BMJ database contains all articles published by The BMJ since 1840 and are in British English. We searched for relevant articles in July 2022. The search was restricted to articles written between 1960 and 1980 to reflect the relevant period of widespread medical migration to the UK from South Asia.2 The search terms used were broad and included ‘India’, ‘Pakistan’ and ‘Asia’ and were input into the search function of The BMJ search website with a total of 115 articles identified. All articles which mentioned IMGs from India and Pakistan were included. Articles unrelated to doctors, for example, about tropical diseases and global health, were excluded and a total of 39 articles were identified. A further screening and manual search was conducted by reference searching and citation tracking of the eligible articles to identify any further relevant articles (figure 1). Two researchers (ZA and MAR) conducted the search and screening of articles. A total of 60 were included in the final review and formed the dataset. The final set for review included 1 book review, 12 original articles, 1 which was described by The BMJ as a middle article, 1 medical practice and 45 commentaries which are presented in a table (table 1).

Figure 1

Arficle screening and inclusion process. CDA, critical discourse analysis.

Table 1

All included articles

Data analysis

All 60 included articles were then reviewed independently by two researchers (ZA and BD) to form the basis of the analysis. The analysis is built on extracting relevant quotations and themes alongside detailed notes from within the text to build an archive of data. Exploration of the data involved analysing the texts to identify dominant discourses and their strands and in keeping with Said’s contrapuntal analysis, to uncover hidden or marginalised voices and perspectives. Particular emphasis was given to the exploration of multiple ideologies or power dynamics within the given discourses and in the context of relevant literature. We revisited the dataset following further literature exploration and used an iterative approach to build the dominant discursive strands. We conducted further analysis of the dataset using AntConc software to help describe some of the common words, phrases and strands used throughout the data.

Reflexivity

We were cognisant of how our own experiences and values influenced this research. The researchers involved in this study came from varied professional backgrounds and lived experiences. This helped provide a balanced approach to this study whereby regular meetings, supplementary note-taking, open discussion and reflexive practice on the authors’ beliefs and views were conducted to minimise bias and challenge findings. ZA and MAR are not IMGs but have Pakistani family origins while BD and CRW do not. ZA, CRW and MAR are practising academic physicians while BD has a background in Applied Linguistics who at the time of this study worked as a research fellow. Additionally, two of the researchers (ZA and MAR) are based in the UK while two (BD and CRW) are based in Canada, a similarly high-income country with a history of inward medical migration from South Asia. None of the author’s team were in professional work or study during the study period of 1960–1980.

Results

Commentaries provided a particularly rich source of data as they were written in the first person and often threads with responses and rebuttals. These threads provided a sense of narrative through the voices of both IPIMGs and their Domestic British peers. Many of the authors described themselves as IMGs or equivalent while others were identified as being domestic peers by the review team which were made holistically based on the descriptors in the presented articles.

The dominant discourse throughout this corpus was one of ‘opportunity’. We further identified four discursive strands that we will outline here: training opportunities, missed opportunities, opportunity for superiority and opportunity to oppose. Each strand often reflected the contradictions and varied perspectives among writers. The quotes used below provide examples of the language and text used or are illustrative of the overarching strand.

Training opportunities

Our analysis uncovered clear discursive conflict surrounding training opportunities for IPIMG. A number of doctors expressed that better training should be available given that they had come to the UK with high hopes for better development opportunities. In spite of these hopes, they felt that they

do not get the opportunity to work in the teaching or semi-teaching hospitals although their primary object is to learn the best this country can offer.38

Some IPIMG conveyed gratefulness to British systems for training, but a contrapuntal analysis reveals the possibility of an implicit understanding of the importance of being outwardly and publicly grateful to the British systems for the opportunities they provided. This was supported by the overwhelming sense of injustice expressed at the inequality of training opportunities, whether that was being appointed into posts or making career progress:

In England it appears one must know the right people to advance; work in teaching institutions instead of working in peripheral hospitals-and that is next to impossible for foreigners39

… the first step in compiling a short-list is to exclude all Indian and Pakistanis.40

This discrimination was described as ‘snobbery’,40 ‘dishonesty’41 and ‘lack of integrity’41 on different occasions, although most typically the language was understated and courteous:

I have yet to see one instance where an Indian doctor (even with better qualifications) was preferred to an English doctor.42

Missed opportunities

A further related strand was missed opportunities. There was a clear sense that an opportunity had been missed to recognise and celebrate the valuable and effective contribution made by IPIMG. It captured this community of doctors’ sense of dissatisfaction and unfulfillment, particularly related to the provision of labour and accusations of incompetence.

IPIMG doctors argued that they were providing ‘help… in running the NHS’,43 and the expected appreciation had been lacking among the medical community leading to feelings of regret, unappreciation and missed opportunities. This discourse exposed that the medical community recognised the negative impacts of migration and potential ‘cynical’44 importation of these IPIMG. They filled a critical gap at reduced cost to the NHS, but their recognition was to be called ‘cheap medical labour’45 that was ‘welcome when the NHS badly needed overseas doctors’45 and to have their competence questioned, and their presence dismissed or challenged.

Some British doctors went so far as to openly write about South Asian doctors as ‘cheap’46 who were inferior to British counterparts.

Further to this was the notion that IPIMG should only be providing cheap labour and any aspirations they may hold to develop in their career would ultimately lead to feelings of ‘resentment’47 and ‘bitterness’.47 Through contrapuntal analysis of the data, it is possible to uncover a gentle resistance to this position, as IPIMG unassumingly point to the fact that various institutions are responsible for this cultural trend. For example, there was an intimation about the lack of sensitivity shown to IPIMG by the UK national medical regulator, the GMC,47 as well as to The BMJ as being ‘knowingly responsible’48 for what it publishes.

Opportunity for superiority

The assumed superiority of British Medicine and diplomas was emphasised in statements within this dataset, with one doctor describing Britain as the ‘original homeland of our medicine’,49 and the Membership of the Royal College of Physicians as a ‘magic diploma’50 that was coveted by Indians. Notably, an Indian doctor later affirms this sentiment and states that it was this ‘hankering after British qualifications’51 that leads to doctors providing ‘back leg medical labour’.51 A contrapuntal reading of this suggests that the honour associated with providing and pursuing high quality diplomas is being used as a discursive device to justify any injustices that may be taking place. In other words, IPIMGs are permitted to acknowledge their maltreatment because they have themselves justified it by coupling it to the benefits they receive from the reflected glory of British superiority.

The opportunity to be a part of the medical community, superior or not, is also highlighted. However, there is a discursive conflict within statements here; on one hand, there is bitterness about the presence of ‘foreign doctors’ and even claims that IPIMGs abuse the facilities of post graduate education and have done so ‘for some time’.52 This is countered with statements recognising that there was a huge dependence on Indian and Pakistani doctors in the NHS and that if Indian doctors returned home then the situation in the NHS ‘would become dangerous’.53 Simply put, IPIMGs simultaneously were needed in the apparent British medical system and were also not desired to be a part of the British medical profession depending on what was advantageous to the British to claim.

A noteworthy area of discord in confrontations in these texts relates to the difference between general and specific statements. British doctors often challenged notions of competence by making sweeping and general statements about groups of people, for example, by highlighting the perceived inadequacy of education provided by schools in developing countries:

many doctors have in the past been reaching this country with pre-graduate knowledge that is so scanty that all the postgraduate training in the world will never make them competent.54

However, opposing statements from IPIMG tended to refer to competence as it relates to individual doctors rather than a characteristic of an entire group.

A further dimension in this discursive strand is related to linguistic discrimination against IPIMG and their English-variant accents and dialects, and language backgrounds which focus on the sound rather than the accuracy of English. English proficiency among IPIMG was regularly cited and also linked closely to notions of competence:

if the foreign or Commonwealth applicant cannot easily speak or understand colloquial English, it would be wrong for him to be appointed in preference to a native graduate, even were the latter less brilliant academically.55

It is framed as the responsibility of IPIMG to improve their English language and enhance their understanding of British culture to help them integrate into the UK medical profession, although there was little support for, or discussion about, development and training investment to facilitate them to do so.

Opportunity to oppose

An important strand of the opportunity discourse involved points of conflict between IPIMG and British doctors. Several commentaries within the dataset highlighted the plight of Asian doctors who felt attacked and demeaned by comments made about them in The BMJ, prompting them to defend themselves. The specific accusations of inability, inferiority and inefficiency suggest that were seen as substandard and second tier in comparison to British doctors. One IPIMG pointed out that ‘all British doctors are not brilliant’56 As well as pointing out the default positioning of IPIMG as inherently inferior to British doctors, a contrapuntal reading allows us to additionally recognise a form of resistance that decouples clinical competence from racial background. This is a common nativist narrative whereby the socially constructed concepts of race, class and language are connected.57 There was a higher bar of expectation for IPIMG which perpetuated a perceived disparity in evaluation and recognition between the groups, which is echoed by another IPIMG reflections on how to break discriminatory tropes:

It takes more than average efficiency and boldness to disprove this.58

Across the dataset, British doctors tended to adopt a more hostile and persecutory stance. IPIMG’s responses were typically defensive. This confrontational dynamic plays an important part in framing the overall discourse of opportunity, as it centres around the opportunity to defend oneself. The confrontation sometimes manifests as a battle, where individuals refuse to let comments go ‘unchallenged’.59 It is clear that some exchanges cause offence and evoke emotional reactions, for example, forcing IPIMG's to reaffirm their commitment to the UK and pleading that they have ‘faithfully and efficiently served the NHS’.60 Some contributors examined the roles and responsibilities of The BMJ in condoning these statements and providing a platform for the expressing problematic opinions, recognising that the wide readership of the journal across the medical profession in the UK made these exchanges potentially consequential and impactful.

Discussion

This Saidian CDA uncovered a complex set of discursive strands that frame how IPIMG navigated their place in the British medical profession during the early periods of migration of this community of doctors. The discourses followed the themes of opportunity based on responses made by various members of the medical community.

Choosing an archive from the most prestigious and popular journal that contributed to the medical professional discourse at the time allowed us to understand that it was considered acceptable to demean and challenge South Asian doctors openly. A contrapuntal analysis of these texts also illuminated that IPIMG’s perceived injustice and inequality and recognised some of the discursive contradictions, for example, that they were simultaneously welcomed and unwelcome in the British NHS. Given that these sentiments were possible to express in this formal space, it is conceivable that opinions more extreme still may have been expressed less publicly.

Our aim was to explore the impact of historical discourses on current trends and discourse manifestations and this study fits within a growing ‘anti-racist’ literature in current medical education and reaffirms previous studies that have found CDA an effective tool in this approach.61 Likewise, it fits within a growing literature that is connecting postcolonial studies and medical education.37 62–64 In recent times, medical education scholars have exposed discourses of ‘medical globalisation’ that perpetuate North-South divides and have roots in historical colonial effects.65 Similarly, Eichbaum et al66 ‘explore the lingering impact of colonialist legacies on current global health programmes and partnerships’. They describe how ‘decolonised’ perspectives have not gained sufficient traction and how inequitable power dynamics and neocolonialist assumptions continue to dominate. Meanwhile, Lokugamage et al67 emphasise how the legacy of colonisation within healthcare continues, although discourses have perhaps moved from explicit outcries of IMG competence to more implicit biases. Majid68 highlights that increased GMC referrals for ethnic minority doctors persists and like we do in this study, discovers the central importance of the ‘dynamics of belonging’.

Competence as a colonial discourse

It is, therefore, noteworthy that this dataset showed that competence was a dominant discourse used to discriminate against and question the threat to the medical establishment from IPIMGs. And yet, competency-based medical education (CBME) would only emerge as an important model in medical education in the late 1990s and early 2000s.69 Competence in medical education is a multifaceted concept that is subject to shifting discourses and influenced by sociohistorical constructs intertwined with power dynamics70 and our results further demonstrated this. The emergence of CBME has garnered renewed interest and debate in recent years, establishing itself as a dominant discourse.71 Contemporary authors have critiqued CBME’s current dominance for being ill suited within the medical profession and lacking sufficient evidence to support its implementation.72 73 Meanwhile our findings showed that competence has long been a dominant discourse and tool particularly within a postcolonial Britain setting and contributed further nuance to the CBME maelstrom. Brightwell and Grant74 build on this further by describing how competency-based training is significantly influenced by political and societal changes and can inadvertently disempower trainees, emphasise minimum standards and diminish the benefits of a rich pattern of learning. This suggests that the use of notions of competence in this dataset foreshadowed how this would later become employed in attempts to standardise medical training. Indeed, Martimianakis and Hafferty75 shed light on discourses surrounding global physician competency, noting a trend towards standardised physician training that transcends geographical and cultural boundaries.

A history of differential attainment

Woolf characterises differential attainment as an ‘institutional problem that requires openness and strong leadership’.76 Our findings uncovered historic vilification of IPIMG that may help to understand notions of discrimination that are deeply ingrained in the Western, in this case British, medical psyche. Despite many decades of interventions from the medical education establishment, issues of differential attainment and racism based on this discrimination persist in the British medical training system.77 Enhancing standards for IMGs remains imperative as a policy goal, as patient satisfaction is adversely affected when healthcare professionals encounter discrimination.78

It is important to acknowledge the role and responsibility of The BMJ in providing a platform for the exchanges uncovered in this study. By publishing views discriminatory to IPIMG, The BMJ may have contributed to legitimising negative views about these doctors and ingraining them into British medical culture, although it did typically also provide a platform for rebuttals and resistance from IPIMG. Although it is beyond the scope of this study to examine editorial decisions by the journal and interrogate manuscripts that may have been rejected and not published, this study reaffirms the importance of professional journals in giving and amplifying voices to different social actors.

Strengths and limitations

A strength of this study is its interpretive analysis using a theoretical approach that is relatively new to medical education scholarship. The varied personal and professional backgrounds of the review team provided a broad range of ‘insider’ and ‘outsider’ perspectives that helped to interrogate the data fully. The dataset also presented many unexpected opportunities, particularly as published letters to the editor allowed personal exchanges in a way that is less frequently seen in modern medical journals.

A limitation of this research is that there was no triangulation with other journals or publications. Although there is no obvious contender that captures the voice of the British medical profession in quite the same way as The BMJ, we cannot say that the voices read here reflect other contexts, especially since this was in a time period before the introduction of other methods of communication like social media. Likewise, we did not interview any of the publication authors. As such, we could not check with the primary authors to confirm their identity, ethnicity, professional background or our interpretations. Additionally, our findings are an interpretation of language used by others. Finally, as with any search strategy, it is possible that some important texts may have been missed despite using multiple methods of identification.

Implications for practice

Issues of racism, discrimination, bias and differential attainment persist in British medical education and continue to negatively impact South Asian doctors such as those from India and Pakistan, including IMGs and those who have graduated in the UK.77 These challenges extend beyond the UK into a global health issue since this trend is mirrored in other countries globally against different minority groups. This study helps to uncover some of the tensions and struggles that emerged in the early period of migration to doctors in the UK, particularly highlighting the importance of analysing this period since it took place a short time after the South Asian region gained independence from centuries of British colonial rule. Recognising that sweeping claims of incompetence were made against these doctors but were also met with deferential resistance to, demonstrated an environment of cultural oppression. That this was allowed to play out in a highly influential and prestigious medical journal is also noteworthy and suggests this was institutionally enabled. Exposing the historical discourses that existed help position contemporary trends and while they cannot provide direct implications, they can provide some illumination on how current discourses have emerged. Policy-makers and practitioners seeking to tackle modern issues of inequity could look back at these events to help appreciate how deep-rooted and systemic they are and to design their interventions accordingly.

Implications for research

Historical research is an important tool in medical education scholarship and the approach of ‘looking back to move forward’ has been compellingly outlined.27 This study furthers this movement and contributes to a growing antiracist agenda that seeks to use methods from other fields, including postcolonialism, to bring richer perspectives and understandings to medical education79–81 Further research in this area could build on our work by using Saidian approaches including contrapuntal analysis to amplify marginalised voices and understand the social realities of medical education in light of the enduring legacy of colonialism. While we have uncovered the early discourses linked to IPIMG in British medicine, an approach that allows the tracking of discourses over time, such as Foucauldian genealogy, may help to uncover how these positions have evolved over time. Finally, further work examining the changing role of major medical journals in capturing professional discourses also warrants further attention.

After centuries of British colonial rule, India and Pakistan gained independence at an important moment in global history that marked the end of the Second World War and shifting geopolitical events. The struggles that Britain faced to establish its ambitious experiment to build an NHS were ameliorated by a large cohort of IPIMG who left their own fledgling nations to help the country of their former colonial masters. This study transports us back to this period and highlights the tensions and contradictions of the time. IPIMGs were playing an indispensable role in the British medical system and were typically having to make sacrifices regarding career choices and preferences to do so. Despite this, they faced considerable criticism and hostility from their British counterparts.

The discourse of opportunity identified in this study is noteworthy in many regards. On one hand, it illustrates how IPIMGs were encouraged to accept their grievances by being grateful for opportunities to be part of a system and tradition that was projected as superior to their own. On the other hand, though, it highlights an opportunity for these doctors to defend themselves and use the prestigious platform of The BMJ to make their case and redress the balance. This latter point is especially apparent through the contrapuntal method. As Said notes, it was never the case that the imperial encounter ‘pitted an active Western intruder against a supine or inert non-Western native’ because ‘there was always some form of active resistance’.36 It is this resistance from IPIMG that is particularly noteworthy given that several decades later, many forms of oppression and inequity have been allowed to persist.

Conclusion

Drawing on this historical analysis, we urge the medical education community that we use it to inoculate ourselves against repeating the injustices of the past, as well as to understand more deeply the antecedents to our current reality.

Data availability statement

Data are available on reasonable request.

Ethics statements

Patient consent for publication

References

Footnotes

  • Handling editor Helen J Surana

  • Contributors ZA contributed to the design of the study, data collection, data analysis and interpretation, drafting, critical review of the manuscript and is guarantor. BD contributed to the design of the study, data analysis and interpretation, drafting and critical review of the manuscript. MAR contributed to the design of the study, data collection, data analysis and interpretation, drafting and critical review of the manuscript. CRW contributed to the design of the study, data interpretation, drafting and critical review of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests CRW is the holder of the BMO Financial Group Chair in Health Professions Education Research at University Health Network.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.