key: cord-0278015-1ezjdjgn authors: Lavallee, J. F.; Conen, S.; Corfield, D. R.; Howells, J.; Pugh, M.; Hart, J. title: A qualitative study exploring the experience of the Medical Intern Programme: Supportive transition for international doctors working in the NHS date: 2021-06-14 journal: nan DOI: 10.1101/2021.06.14.21258746 sha: 900902e85f68813b39a2cd94bc47c11827b11b78 doc_id: 278015 cord_uid: 1ezjdjgn Background: The UK is experiencing a shortage of doctors. Consequently, the Medical Intern Programme, a unique two year programme consisting of an observership, four clinical rotations at the level of a foundation doctor within an NHS Trust and a postgraduate diploma from a university in the north of England, was set up to enhance the NHS workforce by facilitating the entry of international medical graduates into UK medicine via a supported transitional programme. We aimed to explore the experiences of the doctors enrolled on the Medical Intern Programme. Methods: Semi-structured interviews were conducted via the telephone with seven doctors enrolled on the programme. The interview guide was informed by the research questions and data were analysed using a thematic analysis. Results: We identified four themes that were important in the experiences of the doctors: preparing to work in the UK, feeling supported, weighing up the pros and cons of the programme and comparisons between countries. Conclusions: The Medical Intern Programme successfully facilitated international doctors' transition to the UK and working in the NHS. Support needs to be provided at the organisational, team and individual level including a period of observing and shadowing to enable the doctors to understand the systems and multidisciplinary team working in the NHS. push and pull factors include financial factors, professional development, working conditions and general socio-political factors (Cleland et al., 2016; Nair & Webster, 2013; Takemura et al., 2016) , as well as mobility factors such as visa procedures and active recruitment strategies (Kovacs et al., 2014; Sheikh et al., 2012) . There are a number of challenges with migration on both an individual and global level. Individuals often face difficulties in adjusting and transitioning to the culture of their host country and healthcare system (Bond et al., 2020) . Global public health has recognised the difficulties posed by healthcare workers moving from low-and middle-income countries to high-income countries (Oladeji & Gureje, 2016) . Migration has had a significant impact on the quality of healthcare systems in source countries and is a threat to achieving healthrelated sustainable development goals (World Health Organisation, 2016) . Moreover, areas with greater disease burden have lower numbers of healthcare workers, exacerbating the impact of the healthcare worker deficit. Despite the difficulties of migration for healthcare workers, there are a number of benefits for the receiving country and potential global benefits too. Migration enables the workforce to effectively navigate different cultures and healthcare systems, whilst building global attributes and skillsets; ultimately developing a global mind set in line with sustainable development goals. Thus, the benefits of recruiting international doctors are broader than only reducing the workforce deficit. An additional benefit includes having a workforce that reflects the diversity of the UK population. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 14, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 In 2020, an NHS Trust in the north of England partnered with a University and developed a two year Medical Intern Programme (MIP) to recruit international doctors from one lowand middle-income country in the first instance. Eligibility criteria for the MIP were a good medical degree from a recognised University/medical course similar in structure to a UK undergraduate medical degree course, plus General Medical Council (GMC) registration/Professional Linguistic Assessment Board (PLAB). The aim of the MIP was to reduce some of the workforce deficits, attract the best quality international doctors to the UK and to retain these doctors through professional development in preparation for future training posts. The training needs of international doctors have informed the development of the MIP. The MIP consists of supported recruitment, appointment/visa processes, support with settling in (e.g., advice regarding accommodation, finances), peer group support, a bespoke induction, career development discussions, an observership, four clinical rotations as a foundation doctor within an NHS Trust, a part-time two year postgraduate diploma and eligibility to apply for speciality training in the UK on completion of the course. The diploma is led by the university, with part of the teaching delivered at the NHS trust. Doctors have some protected time for study. Modules include a focus on the NHS, patientcentredness, governance, professionalism and specific clinical practice development. Optional modules include medical education, health services research, policy and management and public health. Often doctors recruited from low-and middle-income countries are unable to access postgraduate courses whilst working with a Tier 2 visa (Trewby, 2017) . Therefore, this is a unique training opportunity for international doctors to work in the NHS and experience a number of different rotations whilst studying for a postgraduate university qualification. We aimed to explore the experiences of the doctors on the MIP to understand their perspectives on working in the UK and the programme. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 14, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 We conducted a qualitative study using semi-structured interviews. At study onset there were nine doctors enrolled in the programme. We used purposive sampling to recruit doctors employed though the MIP at an NHS hospital in the north of England and registered on the Diploma at the partner university. An invitation email explaining the purpose of the study was sent to potential participants, along with a Participant Information Sheet. Those who were interested in taking part were invited to contact the researcher who was not involved in the delivery of the MIP (JL). If individuals agreed to take part, verbal consent was gained. Sample size was informed by the number of doctors enrolled onto the MIP. Due to the COVID-19 global pandemic and restrictions in place, one researcher conducted the semi-structured interviews via the telephone (JL). The interviews were informed by the research aim and included questions such as "why did you choose to apply for the programme?", "how has your experience of moving country been?" and "how did you find the observership?" We did not collect demographic data as the cohort was small and we wanted to ensure anonymity for all participants. Interviews were audio-recorded, transcribed verbatim and proof-read. Names were removed from all of the transcripts to . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 14, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 ensure anonymity and the participants will be referred to as 'doctor' followed by a nonidentifiable number. We managed the data in NVivo 12 and analysed the data inductively using Thematic Analysis (Braun & Clarke, 2006) . All transcripts were analysed by one author (JL) and SC and JH independently reviewed a proportion of the transcripts. Any discrepancies were discussed and resolved. This study was approved by the standing proportionate University Research Ethics Committee. Participants gave their verbal informed consent prior to study participation. A total of seven doctors took part in semi-structured telephone interviews lasting between 29 and 41 minutes (average of 33 minutes). The remaining two doctors did not respond to the researcher. During the inductive analysis, four themes emerged from the data: (i) preparing to work in the UK, (ii) feeling supported, (iii) weighing up the pros and cons of the programme, and (iv) comparisons between countries. All participants were already planning to work in the UK and had gained their GMC registration and completed their PLAB test. Many of the participants were actively applying for jobs in the UK when they heard about the MIP. One participant explained that they had . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 14, 2021. ; https://doi.org/10.1101/2021.06.14.21258746 doi: medRxiv preprint been applying for jobs in the UK for five years. The number of job applications submitted exceeded over 100 for most of the participants, yet they explained that they had not been shortlisted for interviews. "after I finished my GMC registration I was looking for a job in the UK. So I applied for 100, maybe 150 jobs, by the time that the announcement for the programme came out." (Doctor, 2) Two of the MIP stakeholders visited the doctors' home country to deliver a seminar about the programme but doctors from the current cohort did not attend this; some did not know about the seminar and others thought it was a postgraduate diploma only. The doctors heard about the details of the programme through friends, University tutors and Facebook. The doctors explained that those who were eligible to apply for the programme did apply. The doctors explained that the application process was straightforward and similar to other NHS job applications, making the process of applying relatively easy. One participant spoke about the support they received in completing their paperwork, which was new to them, and how quickly Human Resources responded to emails, helping them to feel supported throughout the process. The participants explained that having enough time during the interview was important as sometimes they needed to ask questions for clarity or took a little longer as the interview was conducted in English which was not their native language. "But then he was really, really lovely. He was very; he was really detailed in his questions. He gave me all the time I needed to ask my questions at the end." (Doctor, 7) . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 14, 2021. ; https://doi.org/10. 1101 However, all of the doctors explained that they would have liked more information about the postgraduate diploma, rotations and University fees whilst applying for the programme. This would have enabled them to feel more secure in their decisions, but they understood that this information was not available at the time of interview as this was a new course. The doctors thought that they settled into life in the UK a lot easier because they came with other international doctors from their home country. Supporting each other and sharing similar experiences was invaluable to the doctors. Some of them were close friends back in their home country. Moreover, being placed in a northern city where there was a diverse population helped some of the doctors to settle in as they felt able to be part of the community, especially in regards to their religious beliefs. All of the doctors spoke about how well supported they felt from the stakeholders involved in the programme. Most of the doctors first moved to the UK in August 2020 during the COVID-19 pandemic and this provided additional challenges as the doctors were required to isolate for 14 days on arrival and some shops and local amenities were not open as usual. The local stakeholders provided shopping for the doctors for the first 14 days and then took . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 14, 2021. ; https://doi.org/10.1101/2021.06.14.21258746 doi: medRxiv preprint them on a tour of the local area. In addition, the doctors explained that the "system" here was confusing and different to their home country so receiving help with daily administrative tasks such as setting up bank accounts was helpful. The doctors stated that the team went above and beyond to help them settle in and this made a big difference to them. They did not expect to be treated in this way, but it made them feel very welcome and supported. "I expected people to be professional. I expected them to be pragmatic, but I didn't expect them to treat someone that they don't really know that well, to treat them that well. So it was something that really touched my heart. It was really good." (Doctor, 7) The doctors explained that they met weekly with the MIP lead and this was very helpful. The doctors felt supported as they could talk to the stakeholder about some of the challenges they were experiencing. For example, one doctor explained that they had experienced some difficulties with a colleague on the ward and the stakeholder was able to help with this situation. Being able to discuss a variety of issues with the stakeholder was described as "a relief" by one doctor. In addition, the doctors explained that if they were finding any aspects of the diploma difficult, they could speak with the tutors and knew that they would receive the support they needed. The doctors explained that the learning environment for the diploma was a supportive one where they believe their opinions matter and are provided with the space to express their thoughts. One doctor explained that it does not feel like teaching, rather "it is like talking with a wise friend" enabling a deeper reflection about the learning. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 14, 2021. ; https://doi.org/10.1101/2021.06.14.21258746 doi: medRxiv preprint Before the doctors could begin working in the NHS Trust, they completed the mandatory Trust induction online. The doctors explained that they found only some aspects of the Trust induction helpful such as equality and diversity, but wanted to know more about their role as a junior doctor and how "the system" works. Instead, the doctors learned by asking and shadowing colleagues during the observership. The observership provided the doctors with one month of shadowing other staff members prior to working as a doctor, allowing them to observe practices and learn about It systems and ward processes. The observership provided the doctors with the time and opportunity to introduce themselves to their colleagues and learn about the different roles within the multidisciplinary team. The doctors explained that in their home country the healthcare team was made up of doctors and nurses. As a consequence, the doctors were unfamiliar with the roles of allied health professionals such as physiotherapists, occupational therapists and speech and language therapists. The observership helped the doctors to feel more supported during the transition of moving from one healthcare system to a new one. Initially, the doctors observed colleagues. Some of the doctors explained that the observership was one of the reasons they applied for the MIP. They had heard from peers working in the UK that it was difficult to adapt to working in the NHS. Consequently, the doctors thought that this supported period would be beneficial for them. The observership provided the doctors with the time and space to ask lots of questions and they were gradually given more responsibility which helped to increase their confidence, especially with the computer systems. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 14, 2021. Initially, the observership was planned to last for two months, but this time was reduced to one month as the doctors adapted more quickly than expected to working in the NHS. The quality of the observership appeared to be influenced by the availability of staff members. One doctor spoke about their experience of shadowing a locum doctor for the whole month, and this was problematic as they were not able to observe a range of people and this particular doctor worked very quickly. "In my case it wasn't really helpful because I had to shadow a locum who was more senior than I was, and he was the only doctor, so it was difficult for me to cope with him. He was really fast and I didn't know anything about the system or the methods of nursing and so a lot of the things were different for me." (Doctor, 5) Nevertheless, the doctors explained that both permanent and locum staff members provided them with the opportunity to learn about the NHS and the varied roles within it. Some of the doctors were uncertain about whether the team on the ward was expecting them and thought their colleagues were not always aware that they were international doctors and new to working in the NHS. The doctors found it difficult to know who to shadow and what they needed to gain from the experience. Having clear learning objectives for the observership was suggested as a way to improve this. Finally, two doctors spoke . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 14, 2021. ; https://doi.org/10.1101/2021.06.14.21258746 doi: medRxiv preprint about their concerns of how others in the team perceived their levels of competence due to needing to shadow for the month and that it was "disappointing" to not be helping. The doctors explained that they believed the NHS was a supportive environment to work in where staff can speak with each other about the different treatment options, providing "the opportunity to learn without compromising patient safety". "Sometimes, people come and say "good job", and you know this is really cool." (Doctor, 6) The doctors were pleasantly surprised by the support for NHS staff when they arrived in the UK as they saw signs thanking the NHS and were given discounts when buying items. They believe that "everyone are trying to help each other, they are trying to improve systems, trying to improve the quality of care to the patient." (Doctor, 2) . The doctors were surprised by how much paperwork there was to complete when working in the NHS and it took a while for them to get used to this. They recognised the importance of completing the paperwork, in following the guidelines for procedures and always felt supported in following these procedures. "everyone is trying to stick to what is written. So they have to do a procedure in a specific way, they will do it in the way it's written. There is always people who supervise what you are doing, so there is no, there is slight space for mistakes, from the human effect" (Doctor, All of the doctors discussed how much they enjoyed working in the NHS. They really . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 14, 2021. ; https://doi.org/10.1101/2021.06.14.21258746 doi: medRxiv preprint appreciated having a sufficient amount of resource to use and how these were applied equally across patients depending on their needs. They explained that the system does not discriminate against who gets treatment and who does not, as "every patient has got the right for the highest care". They believed that the NHS as an organisation really cares for people and offers the best care available. every patient who is healthy, not healthy, every patient has got the right for the highest care, the highest delivery of escalation. Whatever his or her disease is, yeah that's really important and the doctors are always supported" (Doctor, 3) The reputation of the University hosting the programme was an attractive aspect for the doctors. The UK University already had well-established links with the University they trained at in their home country and this was helpful for some of the doctors, but others thought it would be beneficial if the programme was open for doctors from other Universities in their home country. The doctors spoke about the financial implications of undertaking the postgraduate diploma. The doctors were not aware of how much the course fees would be prior to starting the programme. Once the course fees had been communicated, the doctors engaged in conversations about how to pay and it was agreed that the fees would be deducted from their salary each month. They explained that it was a burden for them to find . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 14, 2021. ; https://doi.org/10.1101/2021.06.14.21258746 doi: medRxiv preprint the money to pay the course fees each month and at the beginning it was challenging to plan for because they did not know what their take home salary would be. The course fees were described as a "financial investment" by one doctor as they believed the postgraduate diploma would be helpful for their future. Another doctor explained that they did not come to the UK to save money, but wanted to know that they could afford rent and living costs. The doctors' uncertainty regarding their finances was made more difficult as the doctors had to wait some time before receiving their initial salary payment. The financial implications was an important factor that influenced whether or not the doctors would recommend the programme to others. would go with any Trust or service job. Like he would do the same amount of work, and the same hours and get I think a fair amount of money more. So for this I wouldn't recommend coming here." (Doctor, 6) All of the doctors stated that the postgraduate diploma was one of the reasons they applied for the MIP. The doctors explained that the diploma provided them with the opportunity to develop their knowledge of the NHS and critical appraisal skills. These skills were helpful in their work for a number of reasons including facilitating their knowledge of a different healthcare system and providing them with another focus that was separate but related to work. All of the doctors believed the postgraduate diploma added value to the MIP as they thought this would help them in their future roles and applications for speciality training (a Postgraduate Diploma may enhance the chances of a successful application for a Higher . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 14, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 Specialist Training Post). One doctor described it as "an offer you can't refuse". "I applied because my aim was to work in the NHS at first and thought it would be a good opportunity, not just the work but to have a diploma added to this and I knew this may help me in the future." (Doctor, 2) Whilst the doctors saw the many benefits of completing the diploma, they also talked about the challenges of studying whilst working and explained that they were finding it difficult to meet deadlines and reach a work-life balance due to their shift patterns. Moreover, the doctors discussed the disappointment they felt when they received the grade for their first assessment as their marks were much lower than they had expected and had received previously in their home country. The need to have appropriate expectations was important and there was an element of adjustment required by the doctors. The length of the programme was described as "double edged". The doctors stated that it is quite a commitment and thought that others may not apply for the programme if their aim was to enter the training routes as quickly as possible. However, they explained that having two years of employment, rotations and experience within the NHS was beneficial as they were able to gain a lot of varied experiences; and one doctor felt that this was a safe option. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 14, 2021. ; https://doi.org/10.1101/2021.06.14.21258746 doi: medRxiv preprint The doctors explained that the rotations were an important aspect of the MIP and one of the reasons they applied. They explained that over the two year period they will work across four different specialities, providing them with lots of valuable experiences across medicine and surgery similar to the Foundation Programme that other NHS jobs would not provide. one year or six months so that's not a great exposure to the medical practice in the UK. While here I have 2 years of 4 different rotations so this is going to give me a lot more exposure than usual service jobs." (Doctor, 5) However, the doctors explained that they would have liked more information about the rotations and the different jobs they would be working in prior to starting the programme. Initially the doctors ranked their preferred rotations, but found out which rotations they would be completing for their first year once they arrived in the UK. They also stated that they still did not know the rotations for their second year and this was something they thought could be improved for future cohorts. They also thought it would be helpful to understand how each doctor was assigned to their rotation. One doctor explained that it was important for them to experience different specialities in other countries to enable them to make an informed decision about the area of medicine they would like to specialise in. All of the doctors agreed that the role of a doctor can change depending on the health service and country they are working in and two years was a good amount of exposure to the NHS. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 14, 2021. ; https://doi.org/10.1101/2021.06.14.21258746 doi: medRxiv preprint "medicine is the same but the job is not the same at all" (Doctor, 4) All of the doctors talked about the differences between England and their home country. There were two main comparisons made which the doctors explained had impacted on how quickly they settled in. Firstly, the doctors were surprised by the culture in England, in particular the timings of social activities. "Usually we start our days in the evening. The evening is very (laughs) people go out and have a life. In the UK after 5, everything just shut down and you have to stay at home, so the life style of the people is completely different from ours and it gets time to get used to this and also getting the rests, is very difficult." (Doctor, 2) Some of the doctors were uncertain about whether this was due to COVID and the restrictions in place, but they believed this to be a big difference and something that they would need to adapt to. The doctors explained that having a social life was very important to them and it helped them to feel more "energised". They had expected to have a social life whilst living in England and they felt disappointed by this. Secondly, the doctors talked about the weather in England and how much they missed the sunshine. This was something that they were having to adapt to, but were finding it difficult. "It's not the greatest weather in the world and coming from a country that is always sunny, I really, really miss the sun. It's one of these things that I never expected to have to take vitamin D tablets every day because I don't get to see the sun. Because I go to work before the sunrise and come home after the sunset. So I almost never see the sun" (Doctor, 7) . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 14, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 One doctor spoke about the challenges of speaking another language as they thought their English was conversational. They explained that they did not find this problematic in the workplace as they believed medical terminology to be the same in all countries, but it was more problematic in their personal life when trying to meet new people. Another doctor explained that it was helpful to speak different languages as during their observership they took a history from a patient who only spoke Arabic and presented the information to a senior. The MIP is a two year postgraduate programme in the UK offered to international doctors consisting of four rotations in the NHS and a postgraduate diploma. This study explored the doctors' perspectives of the MIP and found a number of benefits, including providing professional development opportunities and supporting the transition of moving country and healthcare systems. The areas for improvement included understanding the cost of the postgraduate diploma and the amount of information available about the MIP. More than a third of registered doctors in the UK have trained elsewhere (Webb et al., 2014) . International doctors dedicate a lot of time to upskilling and completing the requirements to work abroad in countries such as the UK, Germany and the USA. Whilst the move to another country and healthcare system can be desirable, the transition is challenging and supporting doctors to make this transition is beneficial. Many international healthcare workers are often not provided with the opportunity to adapt their skills and knowledge in line with their host country (Ohr et al., 2014) . It is well documented within the literature that many of the international workforce have difficulties with practical issues, . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 14, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 as well as the structures and culture of the host country (Kehoe et al., 2016; Slowther et al., 2012) , which may increase their risk of being referred for fitness to practice (Tiffin et al., 2014) . Within the current study, the support provided to the international doctors was viewed as a unique opportunity. There was a team-based approach linked with strong leadership that facilitated the doctors' transition to working in the UK and within the NHS. However, some doctors explained that they thought their colleagues were not always aware that they were international doctors and new to working in the NHS. Therefore, educating and supporting existing staff may also be important for the overall success of the transition for international healthcare workers. Successful recruitment, transition and retention of international healthcare workers has been found to be influenced by organisational support (Ohr et al., 2014) . Organisational support may be demonstrated in a number of ways. The doctors in the current study explained that being provided additional time in their interview was really helpful and having their needs recognised was an important factor in helping them to feel supported. Depending on the stage of their career, international doctors may need different interventions to support their needs. We have demonstrated that the observership and introduction to the NHS were really important aspects of the MIP and one that the doctors found helpful and attractive, even if they had already worked in the NHS. Induction programmes are implemented across NHS Trusts, but often there is insufficient consideration provided to the content of what is needed for international doctors and how long for. In addition, it would be impractical to try to adapt generic inductions to include specific needs of groups. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 14, 2021. ; https://doi.org/10.1101/2021.06.14.21258746 doi: medRxiv preprint A realist review of 88 studies found that interventions were more likely to be successful if they targeted individual needs within a supportive learning environment where support was provided by both peers and supervisors (Kehoe et al., 2016) . Kehoe et al. (2016) provide a number of recommendations for implementing interventions to support international doctors including having cultural awareness within a programme, individual needs assessment and the provision of information about work, culture and general issues at the earliest opportunity. Moreover, successful transitions are facilitated by social networks that provide support and exchange information (Schumann et al., 2019) . Such social networks enable members to develop and maintain their own identity, as well as share the beliefs and practices important and relevant to their culture. Whilst the programme content and delivery are viewed as important, having an organisational culture that is welcoming and creates social support can have a big impact on how well international doctors transition into their host country (Kehoe et al., 2016) . Interestingly, the participants in the current study wished to come to the UK and embark upon the MIP despite not knowing the details of the programme; suggesting that they perceived a number of attractive components within the MIP including the early organisational support during recruitment, the observership and the opportunity to complete a postgraduate diploma alongside rotations. Recruiting and retaining international workforce is important for the NHS, but we need to recognise the potential impact that this has on low-and middle-income countries. The World Health Organisation has warned that there could be a global deficit of 750,000 doctors by 2030. Consequently, there is a need to focus on collaboration rather than competition (THET, 2019). However, the Medical Training Initiative "train and return" . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 14, 2021. ; https://doi.org/10.1101/2021.06.14.21258746 doi: medRxiv preprint included within the NHS long-term plan requires further development as many international doctors plan to leave their home country and do not necessarily plan to return. There are some limitations in this study. Firstly, the total number of doctors enrolled on the MIP was nine and all of the doctors were from the same country. Consequently, our sample size was small, but our sample size and findings were similar to other studies exploring interventions to recruit and retain international workforce (Al-Mohawes et al., 2021; Subedi et al., 2020) . Secondly, we were not able to collect demographic information as this was a small sample and we prioritised anonymity. In future, it will be helpful to gather demographic information to learn more about the cohort and contextualise the findings further. Finally, we collected data from the doctors only. We plan to collect data from the doctors and stakeholders at different points across the next two years and this will enable us to take a holistic view of the MIP. It would also be beneficial to gather data from the Trust and staff who work alongside the international doctors to explore what support they may need. International doctors are keen to work in the UK and develop professionally. This study highlights a number of important factors when recruiting international doctors to the NHS. Firstly, the importance of delivering a programme where doctors' professional developmental needs are recognised and supported. Secondly, the importance of encompassing additional support from the organisation and peers within programmes for international doctors. There are a number of additional needs that must be considered . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 14, 2021. ; https://doi.org/10.1101/2021.06.14.21258746 doi: medRxiv preprint when recruiting and employing international doctors, and the MIP is one of the first programmes to address factors such as peer support, the social situations of the doctors, cultural differences and professional development. This study was approved by the standing proportionate University of Manchester Research Ethics Committee. All participants provided verbal consent in line with the ethics approval and using the University of Manchester's consent form. The datasets generated and/or analysed during the current study are not publicly available due to maintaining individual privacy but are available from the corresponding author on reasonable request. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 14, 2021. ; https://doi.org/10.1101/2021.06.14.21258746 doi: medRxiv preprint Online Bridging Program for new international palliative medicine fellows: development and evaluation The experiences of international nurses and midwives transitioning to work in the UK: A qualitative synthesis of the literature from Using thematic analysis in psychology Human: Solving the global workforce crisis in healthcare What do UK doctors in training value in a post? A discrete choice experiment Final report of the expert group to the High-Level Commission on Health Employment and Economic Growth Supporting . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted Licensing procedures and registration of medical doctors in the European Union From brain drain to brain circulation and linkage Health professionals' migration in emerging market economies: Patterns, causes and possible solutions Organizational support in the recruitment and transition of overseas-qualified nurses: Lessons learnt from a study tour Brain drain: a challenge to global mental health Doctors on the move: A qualitative study on the driving factors in a group of Egyptian physicians migrating to Germany The authors would like to thank all of the participants for their contributions to this study.. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 14, 2021. ; https://doi.org/10.1101/2021.06.14.21258746 doi: medRxiv preprint JL declares no competing interests SC is a member of the University diploma team DC is a member of the University diploma team and the MIP steering group JH is a member of the MIP steering group MP is MIP programme lead JH is a member of the University diploma team and the MIP steering group No funding was received for this study.Authors' contributions JL designed the study, collected and analysed the data, drafted the manuscript and approved the submitted version. SC designed the study, analysed the data, contributed to the manuscript and approved the submitted version. DC contributed to the manuscript and approved the submitted version. JH contributed to the manuscript and approved the submitted version. MP contributed to the manuscript and approved the submitted version.JH designed the study, analysed the data, contributed to the manuscript and approved the submitted version. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 14, 2021. ; https://doi.org/10.1101/2021.06.14.21258746 doi: medRxiv preprint qualified doctors working within the UK regulatory framework: A qualitative study. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 14, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)The copyright holder for this preprint this version posted June 14, 2021. ; https://doi.org/10.1101/2021.06.14.21258746 doi: medRxiv preprint