cite as: Bamrah JS & Chand K. Medics, Migration and Mental illness. Sushruta 2020 (Mar) vol 13; issue 1: 19-20 ePub 16 Dec'19
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It is a well-known factor that migrants to another country have a higher preponderance of developing mental illness when they arrive to settle in their adopted country. The reasons for these are manifold. It is possible that some of these individuals will already have pre-existing mental illness which is triggered off in a foreign land, but there are other factors which are known to be causative, such as stress of migration, isolation, job issues, etc. The article examines the effects that migration has specifically on the mental health of doctors, as well as the consequences of developing mental illness.
Migration and the NHS
The fact of the matter is that the National Health Service (NHS) has been a benefactor of medical migration over many decades. Indeed, during times of staff shortages, the NHS has relied on countries such as India, Pakistan, Sri Lanka and Bangladesh to fill posts in hospital and general practice1. European Union doctors have also made very significant contributions. By the 1960’s nearly half the junior doctor and non-consultant posts were filled by overseas graduates2. Today, almost 36% of registered medical practitioners have their primary medical qualification from a non-UK country and for the first time, between 2018-2019 more new registrants are trained overseas, than in the UK. The commonest registered surnames on the GMC register are, in order of popularity, Khan, Patel and Smith giving us an idea on the workforce configuration of doctors in the UK. The UK’s response to its own crisis in recruitment and retention continued to rely on international recruitment to fill its vacancies despite the fact that the numbers of medical school places have increased by 50% since the year 20003.
With migration come a number of challenges. Most doctors leave their native countries to seek better opportunities for themselves and/or their families, or in some instances to escape unsafe conditions (refugees). There are three stages to the migratory process4. At the pre-migration stage individuals decide to migrate and plan the move. Stage two involves the necessary psychological and social steps in the process of migration itself and the physical transition from one place to another, and the third stage is the post-migratory stage when the individuals deal with the social and cultural integration in the new society, requiring them to adopt new values and adapt to their new environment. Their next generation will have some similar experiences in terms of cultural identity and stress, even though they are technically not migrants.
Migrant diaries, letters and articles in medical journals have often captured recollections of traumatic transitions of migrant doctors from old to new worlds: the tribulations of bureaucracy, the pain of parting, and the discrimination many of them feel in their adopted new homeland. In most cases the difficulties were short-lived or manageable, but occasionally they were catalysts for mental breakdown. Those lucky enough to secure high achieving jobs might escape the ravages of these stresses, while for those who are less fortunate, qualitative research demonstrates that they will end up in what are regarded as ‘second rate jobs where there are fewer learning opportunities and advancements in careers and more of an element of service delivery, which shatters their dreams and expectations.
Most migrants who arrive at trainee doctor level are ill prepared for making that transition; whilst they are likely to be well equipped in the practice of medicine, the adaptation to a different culture, preparedness for postgraduate examinations and a culture of tighter regulation are matters that many of them struggle to grapple with. Medical migrants might also come with no more than a few pound Sterling in their pockets so they may have underestimated the cost of living, expenses on regulatory and essential requirements such as visas, health surcharge, subscription fees for medical defence, trade union and royal college organisations, professional courses and examinations, add to the stresses they are likely to experience.
Racism and Migrants
The recent high profile cases of a Scottish doctor5 and a senior surgeon6 in the North West have thrown sharply into focus how discrimination by patients can undermine the NHS, and also affect those doctors who are the subjects of such behaviours. In both those instances, involving in a first generation Indian General Practitioner and a second generation Indian hospital surgeon, two caucasian patients had demanded that they see a ‘white’ doctor.
These doctors are brave to speak out. However, this is a common occurrence for many Black and Ethnic Minority (BME) health staff, underreported for various reasons – ranging from not feeling confident to do so, feeling that no one would listen or act, while many feel recrimination from being branded racists. Although we would be regarded as having been successful in our respective careers that span almost eight decades between us, it hasn’t always been plain sailing for us. We have each experienced discrimination, whether that is in exams, interviews or selection to jobs. And there have been seemingly well meaning colleagues who have made remarks that would be considered to discriminatory today. The stress of this, on top of everything else, is unimaginable.
Imperatives for tackling mental illness in medics
The emotional burden of migration to a foreign country is the main contributor to health problems in some of these individuals. Unlike migrants from the general population, medical migrants are unlikely to have pre-existing mental illness and so there are ethical and economical imperatives to ensure that these factors are understood and remedied at the earliest opportunity. Research has shown that availability of career and training opportunities, adequacy of supervision, contract type, salary, satisfaction with life in the host country, and acquiring citizenship are associated with a positive experience for these doctors. It is well within the gift of employing authorities and statutory organisations to make a better effort in ensuring that these factors are earnestly tackled. Not doing so comes at a considerable cost not just to the NHS but to the individual doctor and their families as the consequences of stress and depression are substantial, from loss of income, re-employment issues, visas restrictions, stigma of mental health, and at its worst, suicide of the affected doctor.
The contributions of migrant doctors to the NHS are well known and widely acknowledged. However, if these doctors are to feel valued than employing authorities and regulators must do more in order to support them and so that they can continue to work efficiently and productively.
The authors are grateful to Dr Clare Gerada MBE, FRCGP, FRCPsych for her helpful comments.
About the authors
Prof JS Bamrah is Consultant Psychiatrist and Chairman of BAPIO.
Dr Kailash Chand is retd. GP and Hon Vice-president of BMA.