Psychosocial Working Conditions and Well-being of International Medical Graduates in Australia: Evidence from the MABEL longitudinal survey

Abstract

Background: Shortages and maldistribution of medical practitioners, particularly in rural and remote areas, are some of the major challenges besetting health systems worldwide. In its primary attempt to offset these problems, Australia, like a range of high-income countries such as Canada, New Zealand, UK, and the USA, has been actively recruiting doctors from overseas to work in underserved areas. These international medical graduates (IMGs) represent an important segment of the Australian medical workforce, accounting for over 30 per cent of the active doctor population, with higher proportions in regional and remote locations. Over the last two decades, Australia has been drawing its IMG workforce from highly diverse source countries e.g. the UK, Ireland, India, Sri Lanka, Bangladesh, China, Egypt, Iran, and Zimbabwe, most of which differ markedly from Australia on the bases of language, culture, epidemiological profile and the quality of medical training and technology. Additionally, Australia has more recently been implementing policies to increase self-sufficiency of the medical workforce, which has implications for the career opportunities for IMGs in Australia. Since the turn of the second millennium, a substantial body of literature has developed on the experiences and migration outcomes of IMGs in Australia and other Organisation for Economic Co-operation and Development (OECD) countries. But within that body of literature, as confirmed in the scoping review presented in Chapter 3 of this thesis, few have attempted to study how IMGs rate the general quality of their lives amidst their changing professional and social circumstances. In that context, the overarching goal of this thesis was to add and extend this scarce literature by investigating the effect of changes in the psychosocial conditions of IMGs on their general life satisfaction (subjective well-being or SWB) in Australia. Within this, the three broad research aims were 1) to investigate the difference in SWB and its drivers between international and domestic medical graduates (DMGs), 2) to examine the effect of changes in working conditions on the SWB of IMGs relative to DMGs and 3) to explore the effect of recent regulatory changes on the SWB of IMGs. Methods: The thesis used eight waves of survey data from the Medicine in Australia: Balancing Employment and Life (MABEL) longitudinal study of Australian doctors from 2009 to 2016. It applied standard econometric panel regression models to address the research aims in three separate chapters (i.e. Chapters 4–6). The thesis relied upon the theory of ‘Job Demands-Resource (JD-R)’ model of Demerouti, Bakker et al. (2001) to define and operationalise work-related psychosocial risk factors into components of job demands and job resources. Results: Chapter 4 addressed the first aim of the thesis by examining any subjective well-being (SWB) difference and its drivers between the IMG and DMG groups using the Oaxaca and Ransom’s (1994) linear decomposition method. The results showed that the IMG group was more likely to report lower SWB than DMGs (p-value<0.001). The well-being gap (of 0.101) was small and largely attributable to the groups’ differences in observable characteristics such as psychosocial and demographic factors. Most notably, the IMG group was worse off with respect to self-reported financial security, exposure to work-related psychosocial risk factors, and community integration. These results therefore highlight the importance of the workplace and community context in understanding the well-being difference between IMGs and DMGs. Chapter 5 addressed the second aim of the thesis. Using a fixed effect linear regression analysis, it examined the effect of changes in psychosocial conditions on changes in SWB of IMGs and tested whether the estimated effect sizes differed between IMG and DMG groups, and within IMGs by key subgroups. Results indicated that exposure to high work-related psychosocial risk factors and a low sense of community integration were associated with statistically significant declines in SWB among study participants (p-value<0.01). However, no statistically significant differences in the estimated effect sizes were observed between IMG and DMG groups. Within the IMG sample, the effects varied by arrival cohort, country of training, and specialty. In particular, and unsurprisingly, the SWB of the newly settled group of IMGs (<10 years) appeared to be more affected by poor peer support and a low sense of community integration, compared to their long-established (>10 years) counterparts. Counter-intuitively however, the SWB of relatively advantaged IMGs from majority English-speaking Commonwealth countries (e.g., the UK, Republic of Ireland, Canada) showed stronger declines under low job control (autonomy) than their non-majority English-speaking counterparts. Furthermore, compared to specialist IMGs, the SWB of hospital non-specialists from all socio-linguistic groups was more affected by exposure to excessive psychological and physical workloads. Collectively, these results demonstrate the importance of psychosocial risk factors to the general well-being of medical doctors, with specific IMG cohorts at particular risk. Notably, the results confirmed the importance of addressing the support needs of newly settled IMGs for an extended period, often to date restricted to initial employment in workforce shortage areas of Australia. Chapter 6 addressed the third research aim by examining the impact of a specific policy changes on IMGs’ well-being and labour supply decisions. Using a random effect model with a difference-in-differences (DiD) estimator, this chapter explored the heightened risk of de-registration of recently arrived IMGs when announcements made by the Medical Board of Australia in 2013 reinforced the policy of de-registration if Australian Medical Council (AMC) clinical exams had not been passed within 3 years. Results revealed a statistically significant increase in hours spent on educational activities and an accompanying decline in the level of SWB among limited registrants. These results suggested the relevance of regulatory actions on the behaviour and well-being of IMGs. Thus, while registration decisions in Australia are often made on the basis of public protection, there is a need to closely monitor how such decisions might be impacting the well-being of the targeted professionals. Implications: Overall, the findings provided novel empirical evidence relating to the experiences of IMGs in Australia, measured by their SWB, with important stratifications highlighting the diverse experiences and psychosocial needs of this highly heterogeneous group. Ensuring a conducive psychosocial work environment can be useful in promoting the general well-being of medical practitioners, especially IMGs who still remain an important part of Australia’s medical workforce.