• Global Health
• Health policies and all other topics

There were 281 million migrants worldwide in 2020, representing 3.6% of the world’s population and a 0.1% increase from 2019.1 Like the rest of the population, doctors are migrating in larger numbers.2 Although not a precise measure of migration, the Organization of Economic Cooperation and Development (OECD) estimated in 2019 that almost half a million (16%) doctors practising in the 26 countries of the OECD were international medical graduates (IMGs).3 This proportion increased to 19% in 2023.2 The ongoing worldwide conflicts are also likely to increase doctors’ voluntary or forced migration. IMGs experience broadly similar challenges,4 have lower pass rates in postgraduate exams,5 are more likely to experience discrimination4 6 and have a higher rate of complaints made against them compared with domestic medical graduates (DMGs).7 Medical regulators, including the UK’s General Medical Council (GMC), have been attempting to address these challenges.8 However, there is no universal agreement on the terms used to describe this population of migrating doctors.9 In addition, there are subgroups within the larger group of these migrating doctors who might have different educational, professional and sociocultural needs. It is therefore crucial to accurately define the terms describing the larger group and each subgroup, for example, when reporting on numbers of IMGs, describing experiences of IMGs, conducting research related to IMGs, instigating interventions designed to support IMGs and when measuring progress made to address some of the challenges they face.10 Finally, using consistent terminology allows stakeholders, including policymakers, members of the public and scholars, to locate the relevant literature and join the same ‘conversation’.11

The term IMG is currently the most widely used, figure 1, and the most appropriate to describe a doctor practising medicine in a country different to their country of primary medical qualification (PMQ).9 However, there is still confusion—at times—as to which doctors fit into this group including from national regulatory bodies such as the GMC.9 In addition, there are other terms used to describe this group of doctors that are less accurate, as I will explain.

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Figure 1

Results of search on PubMed14 on the 1 July 2024 for the terms ‘Foreign Medical Graduates’ or ‘Foreign Medical Graduate’ (FMG), and ‘International Medical Graduates’ or ‘International Medical Graduate’ (IMG).

In addition to ‘IMG’, the term ‘overseas medical graduate’ has been used in the literature,12 but its use is in decline. The word ‘overseas’ is used interchangeably with ‘foreign’ as suggested by the Oxford Dictionary13 which defines ‘overseas’ as ‘relating to or concerned with countries across the sea; relating to or concerned with foreign countries’. While ‘overseas medical graduates’ might work for migrants to countries such as the UK, the USA or Canada, it sounds out of place, for example, when describing a Polish doctor with a PMQ from Poland who migrates to Germany to practise, as, clearly, this migration does not involve crossing a sea.

On the other hand, the term ‘foreign medical graduate’ has also been used.12 Until recently, it was the most widely used term, but its use has also been in decline since 2007, figure 1. Unfortunately, the term is also used by the National Library of Medicine14 as a Medical Subject Heading describing the same group of doctors as IMGs. It is also unfortunate that despite using the term IMG, the body responsible for evaluating the qualification of IMGs in the USA is called the education commission for foreign medical graduates.15 The word ‘foreign’ conjures an image of a person who does not belong to a country. The continued use of this word to describe a doctor who migrates to practise medicine in a host country will likely perpetuate their feeling of being ‘foreign’, which is especially unhelpful if that doctor intends to settle in the country. In addition, labelling IMGs as ‘foreign’ is unlikely to have a positive impact on their efforts to socially integrate nor their sense of belonging to the host country.4 16 The lack of a sense of belonging to the host country is one of the barriers preventing IMGs from thriving in the host country.4 It is also difficult to be certain whether the word ‘foreign’ refers to the doctor or their country of PMQ. If it refers to the doctor, then that term is not accurate as I will explain.

The main element defining ‘IMG-ness’ is the fact that the country of practise and country of PMQ are different. The definition does not consider the doctor’s country of birth, country of citizenship or their host country residency status. IMGs are typically born and educated in country ‘A’, attain a PMQ from country ‘A’, then migrate to practise in country ‘B’. However, IMGs could also be born and educated in country ‘A’, attain a PMQ from country ‘B’ and return to their home country ‘A’ to practise, as is common in some Scandinavian countries.2 If a distinction is to be made concerning migration status, then I propose the following terms:

• Migrant IMG: to describe a doctor who migrates (for 12 months or longer) to a country to practise medicine where that country is neither their country of usual residence17 nor their country of PMQ.

• Sojourning IMG: to describe a doctor who moves (for more than 3 months and less than 12 months) to a country to practise medicine where that country is neither their country of usual residence nor the country of their PMQ.

• Visiting IMG: to describe a doctor who visits (for less than 3 months) a country to practise medicine where that country is neither their country of usual residence nor the country of their PMQ.

• Repatriated IMG: to describe a doctor who returns to practise medicine in their country of usual residence (at the time of entry to medical school) after obtaining a PMQ from a different country.

An important aspect of defining the term ‘migrant IMG’ is that ‘the country of usual residence’ is at the time of landing in the host country to practise because most migrant IMGs eventually become citizens of the host country, which in turn becomes their country of usual residence. To emphasise, the nationality and citizenship of a doctor are not indicators of whether they are an IMG or not. On first look, the first three terms might seem too detailed and potentially confusing. However, the period of movement does need to be defined accurately sometimes as it influences the professional and sociocultural experiences of IMGs and the choices that they make, for example, investment in learning the host country’s language or developing intercultural competence.

Specific prefixes could also be used to describe certain subgroups of IMGs, for example, displaced IMGs or refugee IMGs.18 In some contexts, the distinction as to whether the migration was voluntary or forced has important implications, as social integration and acculturation tends to be easier for migrants who chose to, rather than were forced to migrate.16 19 20

Other terms sometimes used in the migration literature are ‘migrant physicians’ or ‘expatriate doctors’.21 For the reasons I described above, these terms are vague as well. They might include all IMGs, they might only include migrant IMGs, or they might include repatriated IMGs as the latter group would also have migrated at least two times. Examples of other terms in use are: overseas-trained doctors/graduates, overseas-educated doctors/graduates, foreign-trained doctors/graduates and foreign-educated doctors/graduates. I will not discuss these terms, as the arguments for not using them are similar to arguments for not using the terms I have already discussed. In addition, the words ‘educated’ and ‘trained’ do not specify whether the education or training was for a PMQ.

IMGs are often compared, or their experiences, behaviours and attainment are contrasted with doctors who graduate from, and practise in the same host country. For the latter group of doctors, I propose using:

• DMG: to describe a doctor who practises medicine in their country of PMQ. This term should be used in the context of contrasting IMGs with DMGs in multiple countries.4 16

• (Specific country) medical graduate: to describe DMGs when the context of the discussion is specific to one host country, for example, when contrasting experiences of IMGs in the UK with UK medical graduates.

There are some noticeable exceptions to the way that the groups of doctors constituting IMGs and DMGs are defined in some countries. The USA22 and Canada23 consider each other’s medical graduates as DMGs, as do Australia24 and New Zealand.25 This arrangement is possible when the language, culture and medical education and training are very similar in two (or more) countries.4 9 Doctors who are not defined as DMGs in these countries are obviously classified as IMGs. In the UK, the GMC has created a third category, European Economic Area (EEA) doctors. I have outlined in another article9 the problem with this extra categorisation and the potential negative impact on EEA IMGs in the UK.

There might be other subgroups of doctors or new subgroups that develop in the future, but for now, I have outline specific definitions of the most suitable terms to describe doctor groups based on country of PMQ and pattern of migration. For all the reasons I mentioned at the beginning of this article, it is important that all stakeholders understand the term ‘IMG’, know exactly what it means and which group of doctors it refers to so that all these stakeholders join the same conversation.