In the same storm, not in the same boat

I arrived in Scotland 25 years ago as an International Medical Graduate (IMG), and I still vividly remember those early weeks in Glasgow. The unfamiliarity of the NHS structure, the subtleties of communication with patients and colleagues, and the expectations around documentation and shared decision-making felt overwhelming at times.

Like many IMGs, I was navigating a new healthcare system whilst simultaneously adapting to a new culture, climate and community. Since those early days, I have grown to love the city I now call home. However, that formative experience shaped much of my thinking and ultimately influenced my commitment to IMG support and advancing equity within NHS Education for Scotland (NES).

Common challenges faced by IMGs in the UK include adjusting to consultation styles that emphasise patient autonomy and shared decision-making, understanding the medico-legal and governance frameworks that underpin NHS practice, and adapting to learning and assessment formats that may not have featured in their original medical education. For many, this transition occurs mid-career, when professional identity is already well formed.

Indispensable contribution to the NHS

International Medical Graduates make an indispensable contribution to NHS Scotland. They bring clinical expertise, cultural richness, multilingual capability and global perspectives that strengthen patient care and enhance team diversity across urban, rural and remote settings. Without IMGs, many of our services would simply not function.

The scale of that contribution is often underestimated. Around 7,500 doctors are currently in postgraduate training in Scotland, and between 18 and 20 per cent gained their primary medical qualification outside the UK. In general practice, the proportion is closer to 40 per cent. Across the wider medical workforce, one in five doctors holds a non-UK qualification. IMGs are not a marginal group. Our NHS depends on them.

Yet many IMGs encounter barriers from the moment they enter the system. Some are practical, some cultural, and some arise from the structure of UK medical education itself.

A steep learning curve

Read more: My experience as an IMG doctor in Scotland

Many IMGs have not previously encountered exam formats that are standard in the UK. Problem-based learning, structured reflective practice and high-stakes OSCE-style assessments may differ significantly from prior training environments. Adjusting to MCQs and OSCEs mid-career represents a steep learning curve. The stark differences in attainment reflect this reality- 85 per cent of UK graduates pass postgraduate exams at first attempt, in some specialties fewer than 40 per cent of international graduates do so. Annual Review of Competence Progression (ARCP) outcomes show similar disparities.

These differences are complex and multifactorial. They do not reflect a lack of competence or effort. Increasingly, we recognise the impact of intersectionality. Many IMGs are also from Black and minority ethnic backgrounds. A growing number have recognised neurodiversity. Socio-economic background, religion and migration experience also influence progression. These factors can accumulate in ways that we cannot ignore.

As clinicians and educators, our task is not to question capability but to create conditions in which everyone has a fair opportunity to succeed.

A stormy sea

I often describe this using the image of people crossing a stormy sea. We are in the same storm, but we are not in the same boat. We share the same destination, yet we begin with different resources, networks and resilience. Equity means recognising what additional support someone might need to reach the harbour safely.

In recent years, NES has taken deliberate and sustained steps to strengthen IMG induction and support. The Advancing Equity in Medical Education Group brings together colleagues from postgraduate and undergraduate education, primary and secondary care, training and non-training grades, and the GMC. This work reflects a clear institutional commitment to fairness and psychological safety across the system.

We have strengthened the trainee voice through engagement and feedback, reciprocal mentoring programmes and the appointment of IMG clinical leads and IMG champions across health boards. Fairer feedback training, cultural humility workshops, bystander and bias awareness sessions, and enhanced exam and neurodiversity support are now widely available. Recognising bias is not about apportioning blame; it is about improving psychological safety and reducing stereotyping in high-stakes learning environments.

Practical and relational support has also expanded. Initiatives such as the Welcoming IMGs New to Scotland (WINS) programme, IMG buddy schemes, IMG induction webinars and IMG mentoring networks provide structured orientation and peer connection. The new NHS Scotland IMG Hub brings together national guidance, board-level information and signposting to training, wellbeing and visa support in one accessible platform.

This progress reflects significant hard work across NES and health boards, often delivered quietly and collaboratively by committed educators and clinicians. The system is not broken; it was built in a particular way. But systems can evolve, and they must.

No-one left without support

At a time when international graduates find themselves central to increasingly loud and sometimes hostile political debate, it is important to be clear - the existence of attainment gaps does not equate to poor performance. There are many high-performing IMG doctors, just as there are struggling UK graduates. The issue is not nationality. It is structure, support and fairness.

If we want a safe, sustainable and equitable workforce, we must understand the diversity within it and respond with seriousness and care. That is not preferential treatment. It is responsible leadership.

We may be in the same storm. Our responsibility is to ensure that no one’s boat is left without support.

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This page was correct at the time of publication. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.