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‘International incident’ — hitches with the Graduate Training Initiative

Some doctors participating in the International Medical Graduate Training Initiative (IMGTI) are staying in Ireland beyond the agreed terms, at times having been encouraged by Irish consultants, trainees and hospitals. The issue has been repeatedly raised at the Joint Committee of the IMGTI, according to minutes obtained from the HSE following a Freedom of Information (FoI) request.

The IMGTI is a collaboration between the HSE and Forum of Irish Postgraduate Medical Training Bodies that was launched in June 2013.

According to the national framework document, adopted in January 2014, the initiative facilitates participants in accessing a structured period of training “as developed by an Irish postgraduate medical training body to specifically meet the clinical needs of participants as defined by their home country’s health service”. 

The period of clinical training provided under the IMGTI is ordinarily 24 months, after which the overseas doctor is expected to return to their country of origin.  “The initiative is aimed primarily at doctors from countries with less-developed health sectors and is not intended to lead to settlement in Ireland,” states the document.

IMG training programmes are provided at either primary postgraduate training level (early- to mid-point postgraduate training) or fellowship level (higher-end postgraduate training).

The initiative “enables Ireland to deliver on its commitments contained in the World Health Organisation Global Code of Practice on the International Recruitment of Health Personnel”, according to the HSE.

At present, there are 189 doctors working in Ireland under the IMGTI.

Pakistan

The College of Physicians and Surgeons Pakistan (CPSP) was the first overseas partner with the IMGTI. However, the initiative has since involved further countries, including Saudi Arabia, whose government sponsors participants. This has been a source of controversy among some Irish doctors due to Saudi Arabia’s dire human rights record.

According to the HSE, it pays for the flights and Medical Council registration and initial accommodation during the “short induction period” for the CPSP programme scholarship doctors.

However, while the IMGTI stipulates a two-year period of training in Ireland, there are doctors undertaking the programme who are seeking to stay on. At times, this is being encouraged by Irish colleagues, against a backdrop of doctor shortages and lack of awareness of the programme’s terms.

An IMGTI Joint Committee meeting in September 2016 noted that “this year, a number of the trainees who completed the two-year programme sought and secured employment in Irish HSE hospitals. This is in breach of the terms and conditions of the programme.”

The minutes reported that an “emergency meeting” was held in Dublin with two senior professors from the CPSP. “It was agreed that CPSP trainees must return to Pakistan for a period of at least 12 months after completion of the CPSP programme.

“Formal communication has been issued to all training sites of this decision. Other measures of control were also discussed and will be explored further with all stakeholders. A number of Irish consultants were believed to be encouraging CPSP trainees to stay and work in Ireland. It is important that training bodies communicate the principle to all their trainers.”

This meeting heard that the HSE had issued “clear communication” to hospital sites “not to employ CPSP trainees, etc” after programme completion. “A number of hospital consultants were still encouraging IMG trainees to stay in Ireland and not return to their sponsoring country. It was important that training bodies sought the support of their trainers in following the IMGTI principles.”

In October, a meeting of the IMGTI Joint Committee was informed that nine CPSP trainees who completed the programme in July 2016 “have returned to Ireland and are currently working in Irish hospital sites. HSE NDTP [National Doctors Training and Planning] was working hard to instruct those sites to withdraw the offers of employment. This was proving difficult, as the CPSP trainees were getting mixed messages to [sic] both Irish consultant supervisors and medical administration.”

Positive

However, a broad satisfaction with the IMGTI among stakeholders was evident from the meeting minutes, albeit with room for improvement. 

The meeting of the IMGTI Joint Committee in September featured a presentation from public health medicine specialist and RCSI academic Prof Ruairi Brugha on the IMGTI “as a case study of managed migration under the auspices of the World Health Organisation”. In-depth interviews with 18 past and present CPSP trainees and 10 stakeholders had been conducted. Trainees’ motivation to undertake the programme, their expectations and experience, professional support, opportunities and future plans were covered.

“Overall, trainees found the experience positive, more so in tertiary hospitals, and felt the governance, structures and efforts have been positively viewed.” Areas for “improvement” were noted as the “hierarchy within NCHD system BST/HST”, “programme preparation from Pakistan not as advanced”, the requirement for longer orientation, as well as provision of “more practical hands-on experience” and more tertiary hospital experience.

Results of an exit survey of CPSP IMGs, who trained under the RCSI and RCPI, were discussed at the October meeting. There were a number of areas for further consideration, including: Training bodies providing comprehensive information on the curricula and requirements of the training programme in advance of the trainee’s arrival; and that hospital sites be informed of the feedback related to them.

An exit survey of trainees who trained under the College of Anaesthetists referred to feedback that was “similar to other specialties”, with a number of participants making reference to the rule around returning to Pakistan and not seeking employment in Ireland.

The October minutes reported on a meeting between the HSE NDTP, Forum of Postgraduate Medical Training Bodies and Sudan Medical Specialisation Board (SMSB) to discuss progressing the initiative. “Amendments to the Medical Practitioners Act may close-off the route to entry to the Supervised Division via PRES Level 2 Exemption, therefore colleges were advised to review the SMSB examinations with a view to seeking IMC exemption from the PRES Level 2 exam.

“The Irish College of Ophthalmologists and the College of Anaesthetists of Ireland have agreed to pilot an initiative, with an intake in July 2017.”

The first CPSP Cultural Liaison meeting was held in October 2016 and key actions included drafting a handbook for IMG trainees, exploring the creation of an IMG website, and regular communication to each training site “around the principles of the programme”, reported minutes from December.

The December meeting minutes also referred to competition from the UK and Canada, which was impacting on uptake of the Irish fellowships.

“Kuwait, through KIMS [Kuwait Institute for Medical Specialisations], had recently withdrawn participation in Irish Fellowship programmes in some specialties, sending their trainees to Canada instead.”

A proposal to update the current training agreements to include wording that trainees must remain on the Supervised Division for the entire two years on the CPSP programme was welcomed, according to the December meeting minutes. This meeting also discussed exploring India as another source country for IMG training. “RCPI currently have strong working relationships with five of the medical schools in India and were happy to explore IMG initiatives with them in their discussion in the first quarter of 2017.

“Further discussion recommended including international trainers coming into Ireland to spend a fixed period of time in Ireland with a view to them developing training back in their home country. It was agreed that this should be included into the IMGTI Strategy.”

Feedback

On a clinical level, participants appear to be generally satisfied that the IMGTI contributes to their development as clinicians.

A paper published last year in the Journal of the College of Physicians and Surgeons Pakistan (CPSP/HSE Postgraduate Overseas Rotational Programme: Residents’ Perspective) found that participants believed the IMGTI had improved their evidence-based decision-making, but they disagreed that the training had “polished their procedural skills”.

Nevertheless, there appear to be communication issues, as well as confusion and dissatisfaction, concerning the terms of the IMGTI.

The Medical Independent (MI) is aware that some doctors from Pakistan participating in the IMGTI are anxious about their job prospects upon return to their home country. Feedback to MI also referred to the stipulation that doctors cannot return to Ireland for at least a year after completion of the programme. This measure appears to have been agreed at the September 2016 meeting of the IMGTI Joint Committee, and some doctors would not have journeyed to Ireland if they had known that this would be the case, MI understands.

A spokesperson for the HSE told MI: “The CPSP scholarship programme is an example of managed temporary migration, whereby trainees come to Ireland for a defined period of time, obtain training and then return to apply these skills in their home country and, in the long-term, strengthen their health systems.

 “The IMGTI Joint Committee, the HSE and College of Physicians and Surgeons in Pakistan require all CPSP scholarship programme doctors to return to Pakistan in accordance with principles contained in the WHO Global Code on the Ethical Recruitment of Health Personnel. The requirement is clear to all medical manpower managers, consultant trainers and programme participants that all CPSP programmes are for 24 months and that after this, all trainees are required to return to Pakistan.”

The IMGTI Joint Committee “has no plans to extend trainees on existing training programmes beyond 24 months. All parties are clear on the requirement to return to Pakistan after this time”.

On programme expansion, the spokesperson said the IMGTI Joint Committee regularly assesses opportunities to enhance the programme. “It is currently the intention of the IMGTI to proceed with Sudan this year.”

 A written response was issued to MI by the Forum of Postgraduate Medical Training Bodies. It said it continues to participate and support the IMG initiative in collaboration with the HSE and Irish postgraduate medical training bodies.

 Prof Ellen O’Sullivan, Chair of the Forum, said that “unique” IMG training opportunities “enable suitably-qualified trainees to gain access to clinical experiences and training that they cannot get in their own country.  Engagement with overseas educational partners has strengthened our relationships internationally and has complemented the overall experience of training in Ireland.”

 According to the Forum, it “looks forward” to developing IMG training opportunities in partnership with the HSE.

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