Afghan and Arab Refugee International Medical Graduate Brain Waste: A Scoping Review

Abstract

The forced migration of tens of thousands of refugee doctors exacerbates a phenomenon referred to as “brain waste”. Based on the Arksey and O’Malley model, this scoping review conducted in SCOPUS, ProQuest, CINAHL, and ERIC via EBSCO examines three decades of peer-reviewed literature (1990–2022) on resettled Afghan and Arab refugee International Medical Graduates (rIMGs) attempting, most often unsuccessfully, relicensing/professional reentry in the USA, Canada, the EU, Australia, and New Zealand. The search identified 760 unique citations, of which only 16 met the inclusion/exclusion criteria. Included publications explored (1) systemic and personal barriers to rIMG professional reentry and (2) existing supporting reentry programs and policy recommendations. The findings point to inconsistencies in evaluating medical education credentials and to racial profiling, inequities, and discrimination in residency interviews. The support provided by some programs was perceived as inadequate, confusing, biased, and gendered. The rIMG personal barriers identified included refugees’ unique limitations and life adversities. The review grasps a collection of isolated support programs with widely varying learning performance, unclear buy-in from residency program directors, and weak policy impacts. This analysis highlights the need for legislated and standardized rIMG reentry support programs to reduce physician shortages, health disparities, and, ultimately, IMG brain waste.

1. Introduction

Per the Association of American Medical Colleges’ report, The Complexities of Physician Supply and Demand: Projections From 2019 to 2034, the US will face a shortage of 37,800–124,000 physicians by 2034 (AAMC 2021). While physician shortages are reaching a crisis level not only in the US but in many other high-income countries (HIC, also known as the “Global North”), the relicensing/professional reentry of International Medical Graduates (IMGs) faces various barriers across healthcare systems globally, depending on the local systems and the IMG. IMGs are physicians who have graduated from medical schools outside the country where they intend to practice. Many countries require a visa for IMGs to practice legally in the country. Nearly 325,000 IMGs practice in the US, accounting for 25% of the physician workforce (AMA 2022). However, the capacity of many more unlicensed IMGs remains unutilized or wasted. A caveat is necessary when addressing the issue of IMGs as a potential solution to physician shortage.

The generic umbrella term “IMG” fails to capture important distinctions between various categories of IMGs. Differentiating between a non-refugee IMG and a refugee IMG (rIMG) is essential in capturing the magnitude of the “brain waste”—a phenomenon describing the forced migration of refugee doctors and their inability to practice their skillsets in their new country. A non-refugee IMG could be a US- or Canada-born person who graduated from an “offshore” medical school. Or it could be an EU-trained doctor who, for various reasons of convenience, intends to practice in the USA or Canada. It could also be any non-US/Canada, non-EU, immigrant doctor who voluntarily moves to the USA or Canada for career advancement. IMGs typically relocate voluntarily for career advancement or training, while rIMGs are forced to flee their home countries due to conflict, persecution, or safety concerns. This distinction creates unique barriers for rIMGs. Unlike IMGs, who generally have access to their credentials and verification documents, rIMGs often struggle to retrieve these due to displacement or instability in their home countries. Both groups face challenges such as passing licensing exams, adapting to new healthcare systems, and integrating into a new culture. However, rIMGs face additional hurdles, including profound psychological and emotional barriers, including trauma from displacement, ongoing instability in their home countries, financial and legal constraints tied to their refugee status, and limited professional networks in their host countries. In addition, while IMGs might have access to established networks and resources to support their professional transition, rIMGs often lack such networks, further isolating them in their host countries. These compounded barriers—ranging from trauma and legal constraints to limited professional networks—significantly hinder the ability of rIMGs to re-establish their medical careers, often making the process considerably more challenging than it is for their non-refugee counterparts. The premigration traumas and everyday post-resettlement life difficulties place rIMGs at a disadvantage when compared with non-refugee IMGs in attempting professional reentry in the host country. We hypothesize that rIMGs, the target population of this study, are more vulnerable to brain waste than non-refugee IMGs due to these additional barriers faced. Although these categories of IMGs have different challenges in relicensing or professional reentry in their countries of destination, some authors do not distinguish between non-refugee IMGs and rIMGs. As lumping together these categories is detrimental to this emerging field of scholarship, this study makes a point to focus on studies that include rIMGs, especially those originating from Afghanistan and war-torn Arab countries like Iraq, Syria, and Yemen, to name a few. We hypothesize that these rIMGs may encounter some of the hardest personal and systemic barriers to professional re-entry in the Global North.

The term “brain waste” of refugee IMGs (hereinafter referred to as rIMGs) refers to refugees’ inability to fully utilize their skills and education in the workplace, resulting in underemployment or unemployment. Nearly 270,000 unemployed or underemployed foreign-trained health workers struggling in the US to pursue work are faced with a challenging process (Law 2021). Many rIMGs from Afghanistan, Iraq, Syria, and Yemen face significant barriers to relicensing and experience “brain waste” in Western countries. To better understand the barriers facing Afghan and Arab rIMGs pursuing professional reentry, a scoping review is necessary to ascertain the state of the field. The review aims to explore the brain waste literature on rIMGs and extract data and develop an understanding of Afghan and Arab rIMGs who have resettled in the US and other HICs. Within the Arab rIMGs group, of special interest to this review are doctors from Iraq, Syria, and Yemen, as these war-torn countries have produced the largest exodus of rIMGs (Zarocostas 2007). According to the World Bank’s Development Indicators database of the 30,000 doctors who cared for Syrians in 2010, 75% have fled Syria by 2020 (Hunter and Youssef 2023). We aim to highlight the importance of adding empirical studies about this population of refugee physicians to this field of research and to support policies regarding their professional integration in their new homes.

1.1. Eroded Healthcare Systems and Brain Drain of Afghan and Arab Doctors

Decades of war in Afghanistan have killed millions of people, forcing millions of others to seek refuge globally (UNHCR 2021). Due to the severity and longevity of the war, the reflected number of Afghan immigrants includes those from the 1990s due to the Afghan conflict and more recent refugees and asylum seekers. This is especially true for the largest Afghan community in Europe, residing in Germany—271,805 Afghans—followed by America and Canada (Ahsan Ullah and Chattoraj 2024). After the Taliban’s takeover in 2021, more than 123,000 Afghans were evacuated abroad (Reuters 2021). Based on the personal experience of the first author of this review, many Afghan doctors worked directly for the US government in health and non-health sectors in Afghanistan between 2001 and 2022, attaining valuable skills in technology, project management, and implementation in line with US work ethics. And yet, by and large, Afghan rIMGs are excluded in their host countries and face unemployment or underemployment (taxi drivers, medical interpreters, etc.).

Since 2003, millions of Iraqis have been displaced, resettling in surrounding countries like Syria, Turkey, Lebanon, and Jordan, and accounting for 25% of all refugees in the United States (Mowafi and Spiegel 2008). In Iraq, a cross-sectional survey conducted in 2016 on Iraqi medical students found that 72.7% of those surveyed reported plans to leave Iraq post-graduation (Al-Samarrai and Jadoo 2018). The main drivers of students’ desire to emigrate were to obtain higher professional training, establish a future for their family outside Iraq, and find safety and security (Al-Samarrai and Jadoo 2018). Another 2016 survey of Iraqi medical schools and students found that 63% of schools reported an impaired ability to provide medical education, largely citing conflict as the reason (Barnett-Vanes et al. 2016). A total of 62% of the surveyed medical students indicated they felt their safety had been threatened, with 56% of these students also reporting plans to leave the country post-graduation (Barnett-Vanes et al. 2016).

The Syrian War, now in its 13th year, displaced more than 13 million Syrians internally and around the world (Reid 2022). Before the war, data from the AMA report that Syrian refugees comprised between 3200 and 3900, or 1.6% of rIMGs in the United States, between 2004 and 2008 (Arabi and Sankri-Tarbichi 2012). This percentage only increased as the war progressed, as demonstrated by a Syrian study in 2016, which revealed that 78% of medical student participants hoped to specialize abroad (Sawaf et al. 2018). That same year revealed the University of Damascus as one of the top 10 international medical schools providing IMGs into the US medical workforce (Alsayid et al. 2019). The extreme violence from the war and the socioeconomic crisis that followed further intensified the migration of healthcare workers, thus diminishing the healthcare system internally while generating a high percentage of rIMGs abroad (Soqia et al. 2024). In the United States, 47% of Syrian immigrants in 2014 had a graduate or professional degree, which was higher than their native peers (37%) and other immigrants (42%) (Zong 2015).

With a population of approximately 24 million people, Yemen’s humanitarian crisis remains one of the most severe. Nearly 82% of the population requires humanitarian assistance—mostly in the areas of food scarcity and education (Jongberg 2016; Muthanna and Sang 2017). Around 23.4 million Yemenis require assistance to survive, including the 4.3 million internally displaced who are seeking refuge from violence and injustice (UNHCR 2022). Hospitals in Yemen face physician shortages, as many doctors fled the country. In 2015 and beyond, medical professionals voiced that their salaries were insufficient to cover normal living expenses, with schools shutting down amidst the war (Muthanna and Sang 2017). As referenced by UNESCO, closing schools indicates a country’s instability (UNESCO 2014). The conflict reduced the focus on education, resulting in less academic success and more migration (Muthanna and Sang 2017). In turn, those who have escaped are less likely to continue their education abroad or to practice in their fields.

1.2. Representation, Advocacy, and Financial Impact of IMG Brain Waste

Although since 2010, the number of IMGs in practice has grown by 18%, the largest number of licensed IMGs are not rIMGs from Afghanistan or Arab countries but “regular” IMGs from India (23%), the Caribbean (18%), Pakistan (6%), the Philippines (6%) and Mexico (5%) (AMA 2021). Physician counts and demographic information from the 2019 American Medical Association Physician Masterfile (Boulet et al. 2020) show that 1 in 22 physicians in the US was an IMG or an rIMG from a Muslim-majority nation, representing 4.5% of the total US physician workforce and that more than half of those originating from Muslim-majority nations (24,491 [50.6%]) come from three countries: Pakistan (14,352 [29.7%]), Iran (5288 [10.9%]), and Egypt (4851 [10.0%]). While Boulet et al. do not explicitly distinguish between non-refugee IMGs and rIMGs, their sample includes Afghan, Iraqi, and Syrian IMGs, most likely refugee IMGs. “More than 25% of all IMGs from Muslim-majority countries graduated from 1 of the 5 following medical schools: Dow Medical College, Pakistan (3433 [7.1%]); University of Damascus Faculty of Medicine, Syria (2897 [6.0%]); King Edward Medical University, Pakistan (2150 [4.5%]); American University of Beirut Faculty of Medicine, Lebanon (1952 [4.0%]); and Tehran University of Medical Sciences School of Medicine, Iran (1727 [3.6%])”(Boulet et al. 2020). While it cannot be assumed that IMGs from Pakistan, Iran, and Egypt are refugees, when it comes to Afghan, Iraqi, and Syrian IMGs, it is sensible to presume that most of them may be considered refugee physicians, as the conflicts in Afghanistan, Iraq, and Syria have forced a large number of doctors to flee their countries, making them rIMGs when applying for medical practice in other countries. Also, the 2008 Global Health Observatory data repository reported that the number of physicians in Syria was estimated at 31,000, with approximately 15 physicians per 10,000 per capita (Arabi and Sankri-Tarbichi 2012).

The financial impact of 40% of underutilized refugees with medical and doctorate degrees in the US is significant. The “deskilling” of highly skilled immigrants, including rIMGs, costs $39 billion in lost wages annually and $10 billion in unrealized taxes among the entire labor force each year (Bachmeier et al. 2016). In addition, rIMGs face many barriers to relicensing. Some of the AMA’s criteria in residency selection are very challenging for IMGs and rIMGs: (a) work experience within a US health facility and (b) letters of recommendation from the US rather than outside of the country (AMA 2022). However visionary the voice of over 40,000 IMG and rIMG members of the AMA may appear to be, the legislative impact of its advocacy in organized medicine remains weak.

1.3. Previous Findings on Refugee IMG Brain Waste

A large proportion of rIMGs originate from low- and middle-income countries (LMICs), where training, certification, and practice standards and processes differ significantly from those of high-income countries (HICs) (Eriksson et al. 2018; Lofters et al. 2014). When transitioning into HIC systems, IMGs and rIMGs are subject to strict compliance measures to ensure they can practice medicine within the standard expectations (AMA 2023; Klingler et al. 2018). While rIMG integration benefits significantly outweigh the drawbacks, initial efforts in the EU have uncovered deeply entrenched prejudiced attitudes and discriminatory practices towards both IMGs and rIMGs (Klingler et al. 2018). In German and Swedish healthcare systems, stringent expectations are often held for doctors from non-European countries (Al Waziza et al. 2023; Eriksson et al. 2018; Klingler et al. 2018). These expectations can range from more scrutiny in practicing medicine to passing language and certification courses to undergoing stricter requirements when navigating the medical licensing process (Eriksson et al. 2018; Klingler et al. 2018). These barriers are formally institutionalized, and health systems develop a culture of enabling discriminatory behaviors, making it even more challenging for IMGs and rIMGs to meet relicensing requirements (Al Waziza et al. 2023; Eriksson et al. 2018; Klingler et al. 2018).

IMGs and rIMGs that come from developing countries with steep medical leadership hierarchies (Fernandopulle 2021) struggle in the US flat hierarchy with work-related practices such as informed consent, paperwork, and confidentiality (Bell and Walkover 2021), working with staff as equal partners in decision-making, and patient-centered care (Chen et al. 2011). Previous studies have also documented that the experiences of IMGs mirror in many ways the experiences of underrepresented groups in the US healthcare system and include workplace bias from supervisors, colleagues, and even patients; social isolation; hostile work environments posing barriers to professional advancement (Chen et al. 2011); or outright discrimination (Chen et al. 2011).

Some researchers have identified important IMG personal limitations in multiple areas (communication skills, lack of familiarity with the care of the opposite sex and mental health conditions, limited knowledge of the healthcare system, patient-centered care and ethical principles, unfamiliarity with self-directed learning, unease with receiving feedback, gender equality, personal space, boundary issues, and personal struggles) (Triscott et al. 2016). However, the fact that Triscott et al., and many other researchers, use the umbrella term “IMG” without clearly distinguishing rIMGs as a special subcategory of IMGs, does not help the knowledge base of the emerging field of rIMG scholarship.

1.4. Research Questions

To better understand the barriers facing Afghan and Arab rIMGs pursuing professional reentry, a scoping review was necessary to ascertain the state of the field. The review aimed to explore the brain waste literature on Afghan and Arab rIMGs resettled in the US and other HICs. We articulated our review questions as (1) what external (systemic) and internal (personal) barriers to Afghan and Arab rIMGs’ professional reentry into the HICs medical workforce exist or are reported by rIMGs? And (2) what training programs and support for Afghan and Arab rIMGs’ professional reentry into the HIC’s medical workforce exist or are reported by Afghan and Arab rIMGs?

2. Materials and Methods

2.1. Methodological Framework

Due to the heterogeneous nature of the rIMG brain waste field, the probing nature of a scoping review seemed to be an appropriate and flexible method. Our review follows the Arksey and O’Malley approach (Arksey and O’Malley 2005) using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (Page et al. 2021; Tricco et al. 2018), Extension for Scoping Review Guidelines (Tricco et al. 2018), and PRISMA-ScR Checklist and Guidelines (Tricco et al. 2018).

2.2. Arksey and O’Malley Framework

2.2.1. Stage 1: Identify the Review Question

We first conceptualized our research question based on a broad review of the literature in several rapid “blast searches”. After finding that brain waste studies were often carried out across various disciplines, professions, and training levels, we opted for a team-based, interprofessional approach. Our 8-member team comprises various roles, disciplines, expertise, skills, and professional contexts: public health, epidemiology, general medicine, psychiatry, medical and cultural anthropology, domestic violence, refugee women’s health, biostatistics, medical education, and health systems. The senior author trained the entire team in literature searches, scoping and systematic reviews, PRISMA, and Covidence, a web-based software platform (O’Brien et al. 2022). For ten months, the team had bi-weekly interdisciplinary triangulation meetings, i.e., authors from different disciplines held weekly meetings to discuss possible meanings and interpretations, generate new insights from data, and navigate across different disciplines. These meetings created a coherent framework for interdisciplinary evaluation, to explore the convergence of perspectives from various fields, analyze data, avoid monodisciplinary bias and limitations (Haeussler and Sauermann 2020), and broaden the conceptualization and interpretation of the constructed themes (Patton 1999; Tiainen and Koivunen 2006).

2.2.2. Stage 2: Identify Relevant Literature

We searched the following five databases: PubMed, SCOPUS, ProQuest, CINAHL, and ERIC via EBSCO. The review was conducted from February to December 2023 for English-written, peer-reviewed studies published between January 1990 and December 2022.

The project’s senior author led a stepwise construction of the search strategy. Between January and February 2023, we conducted a broad literature review in four rapid exploratory (“blast”) searches, preliminary searches, and backward and forward citation reviews to probe search terms, refine our tentative research question and strategy, and define the inclusion and exclusion criteria. The following search terms were chosen: Afghan/Arab/Refugees/Refugees from Afghanistan/Refugees from Arab Countries/Foreign Medical Graduate/International Medical Graduate/Medical Career/Residency/Internship/Postgraduate/Licensing/Relicensing/Brain Waste/Waste/Afghanistan/Iraq/Syria/Yemen/Western Countries/United States/Canada/European Union/Australia/New Zealand.

Subsequent searches conducted between March and September 2023 yielded 926 articles. Each of these articles, along with their titles and abstracts, was imported into an EndNote library and then uploaded into Covidence. Covidence identified and removed 166 duplicate articles, leaving us with 760 articles to be screened based on our inclusion and exclusion criteria.

2.2.3. Stage 3: Selecting Studies

Inclusion and Exclusion Criteria

Articles were assessed for eligibility based on the inclusion and exclusion criteria determined by our scoping review team (Table 1). The study selection process was reported using a PRISMA flow diagram (Figure 1).

Table 1. Inclusion and exclusion criteria.

Inclusion	Exclusion
Studies on Afghan and/or Arab refugee or Special Immigrant Visa (SIV) International Medical Graduates (rIMGs).	Study is conducted on non-Afghan and/or non-Arab refugee IMG populations.
2. Multiethnic studies if they also include Afghan and/or Arab refugee or Special Immigrant Visa (SIV) rIMGs.	2. Book chapters, editorials, commentaries, conference papers, and letters.
3. Peer-reviewed qualitative, quantitative, or mixed methods research articles, scoping, and systematic reviews.	3. Articles published before 1990.
4. Study includes Afghan and/or Arab rIMGs resettled in developed Western host countries (USA, Canada, EU, Australia, New Zealand)	4. Articles published in languages other than English.
5. Study examines the perceived external (systemic) and/or internal (personal) barriers to the professional reentry of rIMGs in the host country, where professional reentry is defined as either (a) medical relicensing; (b) admission to training in another healthcare profession (nursing, allied health, counseling, etc.); (c) admission to a graduate degree program in public health (MPH, PhD, DrPH) or health informatics (MHI); or (d) entry in academic teaching and/or research.	5. Studies conducted in non-Western host countries (e.g., Pakistan, India, Malaysia, Turkey, Russia, Ukraine, Saudi Arabia, UAE, etc.).
6. Study examines federal, national, state, private, or NGO programs developed to support rIMG professional reentry in the host country.	6. Study has not addressed at least one of the seven objectives (5–11) listed in the inclusion criteria.
7. Study examines legislation enacted to support the funding of programs supporting rIMG professional reentry in the host country.
8. Study examines the reflections of participants who passed or failed to pass their ECFMG/USMLE certification exams.
9. Study examines the participants who have been admitted or failed to be admitted to US medical residency training programs.
10. Study examines the perception of ECFMG, USMLE, medical residency training program directors of the Afghan and/or Arab rIMG’s professional preparedness and gaps.
11. Study examines the attitudes of Afghan and/or Arab refugee communities towards the professional reentry of their rIMGs.
12. Doctoral dissertations.
13. Published during 1990–2022.
14. Published only in English.

Figure 1. PRISMA.

Firstly, six researchers of sub-team 1 (Z.C., A.A.S., R.H., L.A., S.A.M.A., and A.M.G.) independently reviewed the remaining 760 articles, screening by title and abstract to determine which articles qualified for inclusion in the full-text review. Researcher A.M.G. was assigned as an arbiter for any conflicting decisions at this step. Secondly, after excluding 733 articles, only 27 were selected for full-text eligibility by sub-team 2 (P.M.K. and A.F.P.) with researcher A.M.G. as an arbiter. At this stage, 21 articles were excluded. After a full-text analysis of the remaining 6 articles, all were identified for inclusion in the scoping review. In addition, after hand-searching references and utilizing other identification methods, 10 more articles were identified, for a total of 16 articles identified for inclusion in the scoping review. The first author (A.F.P.) and the last (senior) author (P.M.K.) conducted the full-text review and data extraction; author A.M.G. served as arbiter.

Interrater Reliability

Interrater reliability, expressed as Cohen’s Kappa correlation coefficient for this review, represents the amount of agreement between reviewers of the literature. We have included an assessment of interrater reliability for our scoping review to verify the process validity and reliability of our study. A member of sub-team 1 (Z.C.) screened each article and then compared the findings with those of another member of sub-team 1 (A.A.S.). A satisfactory Cohen’s Kappa value of 0.87 was achieved.

2.2.4. Stage 4: Extracting, Mapping, and Charting the Data

To begin, we determined the variables of interest as they pertained to data extraction based on our review question. We discussed the variable candidates with all team members and pooled the preliminary results to produce a cross-disciplinary framework to use in our charting of the data. The included articles were charted in Microsoft Excel for Mac 2021 version 16, using the following nine subheadings: (1) “Author’s Information” (full APA citation); (2) “Sample Information: (Country of origin, Sample size, Location, Gender [M and F], Class [level of education, socioeconomic status/SES], Generation [Age range]”; (3) “Research Design”; (4) “Aim of the Study”; (5) “Focus Area”; (6) “rIMG perceived internal and external barriers to professional reentry”; (7) “Training program support for Afghan and Arab rIMG professional reentry”; (8) “Stakeholder support for Afghan and Arab rIMG professional reentry”; (9) “Recommendations to promote Afghan and Arab rIMG professional reentry”. Table 2 displays all the charted data except for the limitations.

Table 2. Charted data.

#	COLUMN 1 Covidence ID Author Information	COLUMN 2 Sample Information	COLUMN 3 Research Design	COLUMN 4 Study Aims	COLUMN 5 Focus Area	COLUMN 6 Refugee IMG Perceived Personal and Systemic Barriers to Professional Reentry	COLUMN 7 Training Program Support and/or Concerns for Refugee IMG Professional Reentry	COLUMN 8 Policy Support and/or Concerns for Refugee IMG Professional Reentry	COLUMN 9 Recommendations to Promote Refugee IMG Professional Reentry
1	(Klingler and Marckmann 2016)	Migrant physicians in Germany originating from Russia, Greece, Poland, Romania, and Iran.	Qualitative study; interviews and content analysis.	To provide a comprehensive overview of the multifaceted difficulties experienced by migrant physicians practicing in German hospitals.	Migrant Physicians/IMGs difficulties faced when working in hospitals.	Personal: Insufficient knowledge of the language, healthcare system, of clinical and cultural competencies, of nomenclature, and of medical colloquial terms. Insuff. understanding of scope of work, responsibilities, of legal reqs. for patient treatment and data, of care processes and technical equip. used within hospital. Systemic: Rejected or discriminated against as foreigners. IMG professional competencies are mistrusted.	Slow and cumbersome licensure process. Published reqs. are ineffective to secure expected competencies. Inappropriate support to deal with difficulties experienced lack of support structures to help with adjustment (e.g., a tutor/mentor to ask questions) and for advancing in postgraduate training, e.g., no structured training plan was handed to participants.	None identified.	IMGs should be trained to learn the German healthcare system to meet Germans’ needs. Diversity inclusion should be improved to reduce IMGs discrimination. Institutional policies should be reformed to ease IMG adaptation.
2	(Kureshi et al. 2019)	IMGs and refugee IMGs in the US; countries of origin not specified.	Qualitative study.	To explore the integration of IMGs into the US healthcare system.	To explore Refugee Physician Integration Programs and Initiatives in the United States.	Personal: Refugee or asylum-seeking IMG pressing immediate personal and family needs conflict with career aspirations. Post-traumatic stress from exile, lack of information on the complex US licensing process, limited English proficiency, and difficulty documenting foreign credentials (especially if they had to flee their country). Systemic: Refugee IMGs as a group likely to be undervalued.	“Welcome Back Initiative” establ. In 2001. 10 centers in 9 states: CA, MA, MD, ME, NY, PA, RI, and WA. Upwardly Global establ. in 2000. In CA, IL, MD, NY. Women’s Initiative for Self-Empowerment (WISE) Recertification Program establ. in 2003 in MN. The IMG Assistance Program Minnesota Dept. of Health (2015). Drexel University College of Medicine (2002). Since 2012 George Washington School of Medicine Medical Research Fellowship Program Washington, DC. Since 2017, UCLA School of Medicine, International Medical Graduate Program.	MN Dept of Health implemented the Immigrant IMG Assistance Program, to provide career navigation, assessment, exam preparation, clinical experience and readiness, and residency application support. In 2014, MS passed legislation creating a new category of Assistant Physicians, for IMGs who have secured a residency position. AK, KS and UT have approved versions of MS law. Initiatives are limited to graduates within 3 years of enrollment in the program thus excluding IMGs whose journeys to US often span several years in refugee camps, making them ineligible.	Expand existing programs, and pass policies to support reintegration of IMGs. This will benefit refugee IMGs and the US healthcare system, in physician shortage areas and areas with foreign-born populations. Diverse patient populations call for an increase in the diversity of the physician workforce.
3	(Lofters et al. 2014)	Total of 483 IMGs currently in Ontario, Canada, originally from South Asia (35.9%), MENA (30.3%), Latin America (7%). 54.4% > 40 years old; 52.3% were male.	Mixed quantitative and qualitative study; thematic analysis approach.	To provide an overview of the experiences of IMGs seeking residency in Ontario, Canada.	Migrant physicians/IMGs difficulties seeking residency.	Personal: poverty, the obligation to send money to family members or friends in their home countries. Systemic: Insuff. information about the Canadian healthcare system. Not enough residency slots, misinformation. Lack of information about medical or alternative career pathways.	None identified.	None identified.	IAs MG brain waste is common, Canadian policymakers should make a priority to reduce it. Need to provide clear information to incoming IMGs and make the residency process for IMGs more transparent. Increase residency slots in Ontario, Canada.
4	(Moneypenny 2018)	Total of 12 IMGs in Ontario, Canada, originally from Iran, Iraq, Jordan, Russia, Nicaragua, Colombia, Uzbekistan, Afghanistan, Pakistan, and India.	Qualitative study, semi-structured in-depth interviews with open-ended questions.	To explore the lived experiences of IMGs in Ontario as they navigate the licensure process.	Neoliberalism, globalization, internationally trained physicians.	Personal: female IMGs have a hard time to study or undertake expected observerships because of domestic and work duties. Systemic: Having a prior Canadian clinical experience is a hidden req. Poor credentials eval. is an obstacle in securing a clinical experience. The official websites opaque, hard to understand, and hard to navigate. The National Assessment Collaboration Objective Structured Clinical Exam (NAC OSCE) is required but the Medical Council website does not clearly state so.	Confusing “support”. The Canadian Comm. and Cultural Competence Orientation program (delivered by the Medical Council of Canada via their website physiciansapply.ca/orientation) framed as “better” and “worse” in the education module essentializes IMGs and their experiences as culturally and clinically inferior.	None identified.	Create a fair and equitable pathway to IMG licensure in Canada by improving the licensure system in Ontario; increasing residency slots; tackling the barriers identified by IMGs.
5	(Sood 2019)	A 31-person sample of heterogeneous immigrant IMG population in Ontario, Canada, originally from India, Pakistan, Egypt, China, Bangladesh, Korea, and Libya.	Mixed qualitative study. Surveys and individual interviews.	To examine the experiences of IMGs, including refugee IMGs in the relicensing process in Ontario, Canada.	IMGs; systemic barriers; financial barriers; re-licensing.	Personal: re-licensing costs, family financial burdens. Systemic: lack of academic and clinical training support. Lack of job opports. in health sector, of opports. to relicense in the IMG specialization, lack of fellowship positions. Lack of coordination between federal and provincial governments; lack of well-trained and well-informed support staff in provincial agencies; prejudice and discrimination.	The Health Force Ontario lacks adequate expertise, information, and resources to help IMGs to navigate the re-licensing process. Instead of offering a training-based re-licensing route to the physicians who were previously licensed and experienced, the current system assigned all IMG physicians to the same initial starting point as recent medical graduates.	Current policies are not sufficient to support the successful integration of IMGs in Ontario medical practice. However, seven other Canadian provinces offer an alternative fast-track route to re-licensing for experienced immigrant IMGs, and this process takes into account their experience and expertise so that they can be integrated into Canadian healthcare community.	Introduce in Ontario a fast-track, unambiguous, transparent, focused training program for IMGs with no barriers to re-licensing. Reorganize the steps of the re-licensing so that training precedes exams. Do not pool in one group IMGs who were never licensed to practice with experienced specialists. Provide academic, clinical, and financial support and employment during re-licensing.
6	(Bell and Walkover 2021)	Total of 28 non-USIMG; 18 male, 10 female. Total of 2 Hispanic, 7 Black or African, 5 White or Caucasian and Middle Eastern, 7 Middle Eastern, and 7 White Only. Countries of 2 IMGs specified as Iraq and Turkey.	Qualitative methods, thematic narrative analysis of two representative cases.	To introduce a new category, “refugee physicians”, to distinguish non-USIMGs who are forced to flee their homelands from other non-US-citizen IMGs.	How physicians are located among forcibly displaced people worldwide, use the term refugee physician for non-USIMGs, and refugee physician term related to licesing challenges.	Personal: Lack of support, not understanding the system, insufficient fluency in English and lack of money and time to attend classes. Clinical experience in the US. Emotional challenges following migration, including loss of country, work, professional identity, social status and social support networks. Systemic: number of years since graduation from medical school, the US health system, expensive and long process of licensing.	None identified.	None identifed.	To make refugee IMGs visible, their potential contributions to their host country in which they live should be made visible. When these physicians can gain US medical licenses and practice the skills they worked hard to learn in a career they love, the US gains needed physicians who have strong clinical expertise. In addition, these physicians bring linguistic and cultural competencies in which the US healthcare system is deficient, often paired with experience and willingness to work in under-resourced settings. As the US faces unprecedented burdens on our healthcare system, it has become increasingly urgent to make visible both the category of refugee physicians and the contributions they stand to make when they are able to practice medicine.
7	(Turin et al. 2021)	Countries of IMG origin not specified.	Qualitative study; compr. internet scan.	To identify existing individual, private, and systemic initiatives and resources that support internationally trained health professionals.	Internet scan, integration, immigrant medical professionals, career pathways.	Personal: include spending a lot of time and energy on the relicensing process while burdened with financial and family obligations. Systemic: insufficient information about a very difficult MD relicensing process.	Some organizations provide support and information to IMGs. AIMGA, HealthForceOntario = on becoming licensed physicians in Canada. Scarce information and resources on alternative career pathways (ACPs) for the IMGs in Canada, who have not been certified as physicians.	Study has identified 16 webpages with information on different alternative careers, regulated and non-regulated, available resources to pursue those careers, and what IMG skills can be transferred to the alternative careers.	More systemic policies and IMG specific and ACPs focused job support programs are required. Research and development of programs to facilitate IMG access to ACPs need to be increased and strengthened.
8	(Abbara et al. 2019).	Syrian IMGs in Germany	Qualitative study.	To discuss challenges faced by Syrian healthcare workers in Germany to enter the workforce.	Integration; host country.	Personal: Syrian refugee IMGs struggle with German language and cultural barriers. Systemic: hard to understand and to navigate decentralized bureaucratic processes and long delays in obtaining original Syrian diplomas and securing credentials’ evaluation.	In 2015, Germany passed a law that allows refugee medical doctors to work alongside licensed doctors in refugee centers, a move which supports refugee doctors, refugees, and the host country, Germany.	Stakeholders (medical associations, politicians, practicing MDs, advocates, etc.) held mixed positive and negative perceptions about the competence and potential of Syrian IMGs.	Policy recommendations include leadership from German doctor associations and policymakers to support the integration of IMGs into the federal health system. Bridging retraining and observerships are needed.
9	(Klingler et al. 2018)	Total of 25 interviews; 14 participants who were stakeholders working in hospitals; 11 participants who were stakeholders from the policy world. Arab countries of IMG origin not specified (except Syria).	Qualitative study; semi-structured interviews.	To explore stakeholders’ opinions and attitudes towards foreign-born and foreign-trained physicians in Germany.	Attitudes, opinions, stakeholders, FB and FT, Arab IMGs.	Personal: poor proficiency in German, not understanding the German healthcare system. Islamic moral, religious, and gendered norms not condoning performance of certain medical procedures on the opposite sex. Systemic: a confusing licensing process. Discrimination.	None identified.	Stakeholders criticized IMGs’ work for deviating from German professional standards (skill or knowledge and behavioral standards). Behavior falling outside the tolerance range was criticized as unacceptable, requiring action to prevent future similar deviations from German norms.	Develop and implement better support strategies for IMGs while also addressing rigid attitudes within the receiving system to the professional integration of IMGs.
10	(Berleen Musoke 2012)	Total of 6 IMGs in Sweden from Egypt, India, Bolivia, Iraq and Russia.	Qualitative study.	To look at the personal experiences of non-European medical doctors that have migrated to Sweden.	IMG; barriers; experiences; prejudice.	Personal: Poor Swedish language skills, loss of social status and support networks. Systemic: The road to getting a Swedish medical license was experienced as confusing and frustrating, and but not as being discriminatory or prejudiced.	Sweden offers a one-year course called supplementary education for professional status qualification for medical doctors, nurses, and dentists.	None identified.	None identified.
11	(Sturesson et al. 2019).	Total of 498 IMGs physicians from Asia (55%), Europe (27%), Africa (13%), Latin America and the Caribbean (9%), and North America (1%). Arabs are included but countries of IMG origin not specified.	Cross-sectional study; descriptive statistical analysis; qualitative thematic analysis.	To explore how IMG’s from outside EU/EEA enter and advance within the labor market in Sweden and identify perceived barriers in the process.	Barriers; IMG; entrance; labor market.	Personal: insufficient language skills. Systemic: having another ethnicity, religion, a foreign name, a foreign medical degree, having the wrong age, having the wrong gender, and lacking work experience and work references from Sweden were associated with perceived discrimination.	None identified.	None identified.	Train employers to increase awareness of own behaviors and prejudices towards IMGs. Have IMGs participate in bridging programs to find employment. Integrate specific language training in bridging programs.
12	(Blain et al. 2017).	Total of 31 participants: 15 women and 16 men. Ages 33–35. French-speaking. IMGs in Quebec from Western Europe (8), Eastern Europe (3), Latin America (9), The Antilles (Cuba and Haiti) (3), Maghreb (4), and Sub-Saharan Africa (4).	Mixed qualitative and quantitative methods. Dynamic analysis; anthropological study; semi-structured interviews.	To understand why individuals of similar occupational groups can easily access doctoral professions.	IMGs; highly qualified migrants; occupational integration; recognition; Quebec, Canada; employment resources.	Personal: Some IMG were affected by the impersonality of the interviews and the feeling of being unwelcome. The counselor supposed to orient IMGs did not know any more about the process than did the IMGs. Systemic: lack of clarity and transparency in the process of medical professional relicensing.	Emploi-Québec or other organizations offering services related to employment integration are not adapted to the profile of highly qualified immigrants—despite the goodwill of those involved.	None identified.	Research recommendation: a longitudinal study on the professional integration of highly trained IMGs is needed to inform policy recommendations.
13	(Al-Haddad et al. 2022).	Total of 57 articles of which 46 described 1142 IMGs practicing in all continents. Databases used were Medline, Embase, Cochrane, PsycINFO, ERIC, EdResearch. Countries of IMG origin not specified.	Meta-ethnography of qualitative studies.	To provide a comprehensive picture of the experiences and challenges that IMGs face before and after migration.	IMGs; migration, experiences; challenges.	Personal: loss of status and high cost in the licensing process. Systemic: a complex licensing process that can take up to 10 years, structural barriers, discrimination, matching, female gender, EU IMGs vs non-EU IMGs, and lack of coordination between institutions of concern.	None identified.	None identified.	IMGs in the study call for more coherence within the different steps of the complex professional integration process along with more feedback, communication, and personalized guidance.
14	(Wong and Lohfeld 2008).	Total of 12 IMGs. 5 women, 7 men. From Asia, Latin America, the Middle East, the Caribbean, and Eastern Europe. Countries of IMG origin not specified.	Qualitative study; semi-structured interviews.	To describe the recertification training experiences of IMGs in Canada to help medical training programs understand how to integrate IMGs into communities.	IMGs; adaptation; training program.	Personal: loss of personal identity, of financial autonomy, inability to fulfill familial roles, loss of professional identity, status, and disorientation. Systemic: a difficult and lengthy recertification process, ambiguous selection criteria, and lack of feedback.	None identified.	None identified.	Medical training programs should support IMGs going through the three-phase process to facilitate by offering faculty and peer mentoring, psycho-social counseling, and educational and orientation activities for IMGs, local trainees, and faculty.
15	(Eriksson et al. 2018).	Total of 11 Internationally Educated Nurses (IENs) and 11 International Medical Graduates (IMGs) from Algeria, Bosnia, Bulgaria, Poland, Serbia, Spain, Sudan, Poland, Italy, Syria, Romania, Greece, Uzbekistan, Ukraine, Colombia, Iraq.	Qualitative study, semi-structured interviews.	To explore how IENs and IMGs describe their experience and perceptions of getting their license to practice in Sweden and how their competence culturally is used.	IEN; IMGs, intercultural competence;lLicense; work experience.	Personal: Swedish language, work and study for licensing, and cultural differences. Systemic: a very long time to obtain licensing, unfamiliarity with the Swedish healthcare system, different policies for EU and non-EU IMGs, bias at the workplace against non-EU IMGs and INGs, and discrimination.	Programs allowed IMGs and INGs to begin supplementary medical and nursing education but did not offer any financial support.	None identified.	Provide more efficient language courses and longer workplace introductions to facilitate the acculturation process. Provided tailored support like visiting a clinic. Provide financial support with supplementary training.
16	(Cohn et al. 2006).	Total of 31 refugee physicians. Of which 20 were re-interviewed 6 months later. Female: 12; male: 19. Age: 22% from 25 to 45 years; 45% were from the Middle East, 26% from Africa, 10% from Asia, 10% from Eastern Europe, 3% from Central and South America, 6% other.	Qualitative study; semi-structured interview.	To explore perceptions and experiences of practicing refugee physicians in psychiatry in UK.	Refugee doctors; perceptions; experiences; IMGs.	Personal: difficulties with the International English Language Testing System (ILTS); poverty, isolation, cultural, and housing issues, family obligations, and financial burdens. Severe stress due to loss of professional identity, social status, and respect. Systemic: Lack of appropriate information, lack of a clear route through the system, and process of MD relicensing. Difficulties in obtaining clinical attachments. Perceived discrimination.	Programs do not provide IMGs with an integrated, detailed, and clear professional reentry path from initial contact through the examinations and placements to finally gaining employment.	Databases of refugee doctors, held by the British Medical Association and the Refugee Council, facilitate dissemination of information. IMGs acknowledged the importance of both emotional and practical support. However, the information was out of date, leading to false hopes being raised. That support might have been well-meaning but was not individually tailored and thus not helpful.	The Royal College of Psychiatrists (RC Psych) already has a method of offering attachments to post-PLAB trainees. It would be helpful if a database of consultants willing to mentor or offer clinical attachments to IMGs was established. Ensure that clinical attachments to refugee IMGs are offered free of charge.

2.2.5. Stage 5: Collating, Summarizing, and Reporting the Data

This stage poses the most difficulty of all of the Arksey and O’Malley Framework steps, as it lacks clear and concise guidance. We followed the steps suggested by (Levac et al. 2010) to complete this portion of the framework: (1) developed a template to summarize and analyze the findings, (2) conducted thematic data analysis, (3) coded for themes that related results to the research question and/or purpose, (4) provided additional analytical depth from the interdisciplinary expertise of our team, (5) presented findings within the context of future research, policy, and practice, and (6) prioritized findings to emphasize implications for future research.

To identify patterns in our dataset, we utilized a thematic analysis. The team discussed possible meanings and interpretations of the data via triangulation meetings. Members included a public health professional with expertise in Afghan refugee health and medicine (AFP), an Arab American researcher in healthcare and medicine (ZC), a public health doctoral student with experience in DV and sexual health (AMG), a medical doctor, a psychiatric epidemiologist trained in cultural anthropology and with expertise in Arab refugee trauma and DV (PMK), and four UC Davis students (2 Afghan-Americans, 1 Iranian-American, and 1 Armenian-American) with substantial work experience at student-run refugee clinics (LA, RH, AAS, and SAMA). We utilized a shared thematic analysis table to ensure that all themes, subthemes, and quoted texts were captured accurately for interpretation.

3. Results

Through our team’s original database search, 926 articles were identified. After removing 166 duplicates using the online Covidence software, 760 remained for screening. After screening based on the title and abstract, 733 articles were removed, leaving 27 to be assessed for full-text eligibility. Twenty-one articles were removed at the full-text stage of screening, for reasons including (1) wrong study design, (2) wrong population, (3) wrong setting, and (4) wrong indicator. Six studies were left to be included based on full-text screening criteria. Other identification methods, such as reference screening and expert knowledge, added 10 additional articles for inclusion, for a total of 16 included articles (Figure 1).

A summary of the articles included can be found in Table 2. Of a total of 19 included articles, 14 studies were qualitative, 3 were quantitative, mixed qualitative and quantitative methods studies, and 2 were systematic reviews/synthesis. Studies included rIMGs lumped together with IMGs from 32 countries: Afghanistan, Algeria, Bangladesh, Bolivia, Bosnia, Bulgaria, China, Colombia, Cuba, Egypt, Greece, Haiti, India, Iran, Iraq, Italy, Jordan, Korea, Libya, Maghreb, Nicaragua, Pakistan, Poland, Romania, Russia, Serbia, Spain, Syria, Sub-Saharan Africa, Sudan, Ukraine, and Uzbekistan. A total of 10 of the 19 articles have not specifically named the rIMGs countries of origin, mentioning only the continent and/or the region (i.e., MENA).

Thematic Analysis

Five main categories were identified for a thematic analysis: (1) perceived gaps in professional standards of rIMG training, certification, and practices in Western healthcare systems; (2) systemic barriers: (a) inconsistencies in the professional evaluation of rIMG and (b) racial profiling, inequities, and discrimination; (3) internal barriers: personal limitations and everyday life adversities; (4) inadequate, confusing, biased, and gendered support of rIMG professional reentry; and (5) recommendations to advance rIMG professional reentry to solve a physician shortage crisis.

4. Discussion

The findings of this scoping review highlight the growing body of literature on IMG brain drain and rIMG brain waste in the host countries, emphasizing the multidimensional impact of these issues and the variety of approaches or recommendations for the reentry of rIMGs into the host countries’ healthcare systems. While several studies report consistent findings regarding internal (personal) and external (systemic) barriers regarding rIMGs reentry into host countries’ healthcare systems, there remains a lack of consensus on the quality of education and medical training curriculums among the target rIMGs in their countries of origin, suggesting the need for more rigorous research to clarify these differences.

4.1. Perceived Gaps in Professional Standards of rIMG Training, Certification, and Practices in Western Healthcare Systems

In our review, several authors note insufficient knowledge of the healthcare system and gaps in clinical competencies, cultural knowledge, everyday language, nomenclature, and colloquial medical terms. This may be especially true for rIMGs, as they often hail from countries with very different cultural norms than their host country. Moreover, some IMGs and rIMGs show a poor understanding of their scope of work and responsibilities, of legal requirements regarding the treatment of patients and data, and of care processes and technical equipment used within a hospital (Klingler and Marckmann 2016).

4.1.1. Systemic Barriers: Inconsistencies in the Professional Evaluation of rIMGs

In the United States, all IMGs must consistently evaluate their educational credentials. This barrier is especially poignant for Afghan rIMG populations. Afghanistan has no unified credit system in the schools and universities, making it incompatible with the US grade point average (GPA) system. Each institution has its own accepted evaluation organization, which can all provide different GPAs, even when all conferring the same Medical Doctor (MD) equivalency (World Education News and Reviews 2016). The British Council Report notes two issues with quality implications in higher education: (a) academic appointments have historically been awarded based on political patronage, not academic merit, and (b) the prevalence of underqualified faculty is well recognized both within Afghanistan and by the many international aid organizations focused, until the Taliban takeover in 2021, on improving the sector.

The ambiguities in the processes and organizations involved in rIMG integration need accurate or standard bases for credential evaluation. The Dutch Organization of the Internationalization of Education (NUFFIC) reported that the European Credit Transfer and Accumulation System (ECTS) had not yet been officially adopted by Afghanistan’s Ministry of Higher Education (World Education News and Reviews 2016). In the USA, until 2016, World Educational Services (WES) did not verify academic documents from Afghanistan. Additionally, some rIMGs were affected by the impersonality of interviews and the feeling of being unwelcome. Medical counselors should orient rIMGs who are unknowledgeable about the process (Blain et al. 2017).

4.1.2. Systemic Barriers: Inequities, Racial Profiling, and Discrimination

Our study confirms and expands on previous studies that demonstrated rIMGs feeling rejected or discriminated against as foreigners, as well as a misjudgment or mistrust of their professional competencies (Al-Haddad et al. 2022; Klingler and Marckmann 2016). Also, female rIMGs and non-EU rIMGs experienced lower acceptance rates than male and EU rIMGs in the match process (Al-Haddad et al. 2022). Meanwhile, Germany and Sweden pose workplace challenges by not welcoming rIMGs altogether (Klingler et al. 2018; Sturesson et al. 2019). While in Sweden, the bureaucratic path to relicensing was not perceived as being overtly discriminatory or prejudiced, non-European doctors, including Arab rIMGs, have described it as disorganized, confusing, and favoring European IMGs (Berleen Musoke 2012).

In Canada, obtaining professional recognition for IMGs can be largely contingent on the racial background of the immigrants (Blain et al. 2017; Jongberg 2016). IMGs from francophone Europe (France, Belgium, Switzerland, Luxembourg, and Monaco) and, to a lesser extent, IMGs from francophone Africa (mainly Algeria, Cameroon, and Tunisia) often have an uncomplicated recognition pathway into the Canadian healthcare system, especially in Quebec. At the same time, those from non-European nations need to navigate alternative pathways to develop their professional community, connections, and clientele (Blain et al. 2017; Jongberg 2016; Lofters et al. 2014; Moneypenny 2018). Market values in Canada for these foreign credentials fluctuate based on IMG racial background (Blain et al. 2017; Jongberg 2016). Not only are many IMGs and rIMGs left feeling disoriented due to varying sources of information during integration navigation but are also made to feel unwelcome and untrusted within specialized practice (Klingler et al. 2018; Wong and Lohfeld 2008; Sood 2019).

4.1.3. Internal Barriers: Personal Limitations and Everyday Life Adversities

In addition to the previous data findings, our study confirms and adds that a majority of rIMGs struggle in post-resettlement with culture shock and disorientation (Kehoe et al. 2016). Most Syrian and other rIMGs struggle with difficult cultural and linguistic barriers (Abbara et al. 2019; Eriksson et al. 2018), performing poorly on the English Language Testing (IELTS) (Cohn et al. 2006). Additionally, many Muslim rIMGs also struggle with Islamic moral and religious gendered norms not condoning the performance of certain medical procedures on the opposite sex (Klingler et al. 2018). IMG refugees or asylum seekers face additional barriers, including pressing personal and family needs conflicting with career aspirations, and post-traumatic stress (Kureshi et al. 2019). As well as financial problems (Cohn et al. 2006), worsened by the obligation to send money to family members or friends in their home countries (Lofters et al. 2014; Sood 2019).

Most IMGs undergo a three-phase process during their recertification process: loss, disorientation, and adaptation (Wong and Lohfeld 2008). While studies have found that adaptation is promoted through adequate support and sufficient exposure to Canadian healthcare systems, disagreements between colleagues and discrimination can set back an IMG’s assimilation progress (Eriksson et al. 2018; Wong and Lohfeld 2008). Thus, the issue therein lies with adapting receiving systems so they are prepared to offer social support and embrace cultural differences (Cohn et al. 2006; Heal and Jacobs 2005; Lofters et al. 2014).

Again, IMGs are not only subject to systemic obstacles to their professional reentry but are still facing personal adversities and responsibilities (Cohn et al. 2006; Eriksson et al. 2018; Heal and Jacobs 2005; Kehoe et al. 2016). It is important to recognize these challenges to provide support and integration pathways and to create opportunities.

4.2. Inadequate, Confusing, Biased, and Gendered Support of Refugee IMG Professional Reentry

Many rIMGs experienced insufficient support to advance in postgraduate training (e.g., a tutor/mentor), and no structured training plan was handed to participants (Klingler and Marckmann 2016). Sometimes, the support was confusing. For example, the Canadian Communication and Cultural Competence Orientation program (delivered by the Medical Council of Canada via their website framed as “better” and “worse” in the education module) essentializes rIMGs and their experiences as culturally and clinically inferior (Moneypenny 2018).

Many rIMGs are forced to be over-represented in general medicine (Sturesson et al. 2021). Their choice, or lack thereof, of employment options, stems from hurdles within rIMG private lives, work environments, and labor market conditions (Sturesson et al. 2021). Synthesized studies of the published qualitative literature and reports from the experiences of over 1000 rIMGs find that some rIMGs even experience discrimination when they are unable to re-enter their first-choice specialty in training, with more women rIMGs opting to just enter general practice than their male counterparts—this hurdle adding another gendered dimension to the experiences faced by rIMGs (Al-Haddad et al. 2022; Moneypenny 2018; Reuters 2021; Sturesson et al. 2021). rIMGs are also generally older than their domestically trained peers due to the extensive retraining and recertification requirements like the one in Sweden (Sturesson et al. 2021).

Considering the heterogeneity of incoming rIMG expertise, it would be beneficial to develop support systems that uphold professional standards while still supporting the diversification of the physician workforce (Al-Haddad et al. 2022; Al-Samarrai and Jadoo 2018; Kehoe et al. 2016; Kureshi et al. 2019). As various authors have suggested, support systems should be established to help rIMGs retrain in alternative healthcare professions to reduce disparities in their refugee communities (Allen et al. 2013).

4.3. Recommendations to Advance Refugee IMG Professional Reentry to Solve a Physician Shortage Crisis

Some authors recommend introducing a fast-track, unambiguous, transparent, focused training program for rIMGs with no implicit/embedded barriers to re-licensing (Sood 2019). Regardless of the reservations held by healthcare systems to accept rIMGs from other nations, and especially those from LMIC nations, there is a significant physician shortage deficit that only rIMGs can solve. Host countries are harming their populations by creating complex and very difficult-to-navigate integration systems while retraumatizing vulnerable rIMGs that could help. The shortage of healthcare workers in Europe makes integrating IMGs, and especially rIMGs, a socially and economically beneficial solution. Germany and Sweden need to expand their medical personnel but are slow-moving in taking the necessary steps to support IMGs in training, certification, and working environments (AMA 2023; Barnett-Vanes et al. 2016; Eriksson et al. 2018).

Due to the significant physician scarcity in Germany, opening access to medical practice opportunities in refugee centers for refugee medical doctors to work alongside licensed physicians could serve as a transitionary pipeline (Barnett-Vanes et al. 2016).

There is an influx of Syrian rIMGs in Germany due to political unrest (Barnett-Vanes et al. 2016). These professionals would help alleviate the physician shortage, and supporting their reentry into the German healthcare system could also help rebuild Syria’s health system when that time comes (Barnett-Vanes et al. 2016).

Facing a significant physician shortage and given the enormous excess of rIMGs across the globe, the US, too, would benefit from implementing a similar model. While still at a small scale, some programs in the US have successfully created multilingual and culturally competent curricula to support rIMGs through the integration processes—a model that should be considered by other nations (Peters et al. 2020; Moher et al. 2009).

The value of cultural heterogeneity in rIMG experiences and skillsets should be included and optimized by support systems tailored to the specific needs, circumstances, and barriers faced by rIMGs. However, 10 articles out of 16 have not expressed any policy support and/or concerns for rIMG professional reentry. It may be that some authors were careful to guard a negative appraisal of rIMG skills and preparedness and/or that they have not seen the need for translational policy changes. It is difficult to interpret this finding, but we strongly recommend further research to investigate this.

5. Limitations and Strengths

5.1. Limitations

Firstly, relicensing barriers confronting Afghan and Arab rIMGs is a relatively new and narrowly focused topic. As such, the scarcity of foundational research on the topic impacted the depth and breadth of our review. Secondly, the exploratory nature of scoping reviews for emerging topics often leads to difficulties in formulating comprehensive search terms. The evolving state of the literature means that even refined search terms may only capture some relevant studies, potentially resulting in gaps in the review. This limitation reflects the inherent challenge of scoping reviews in identifying and refining effective search strategies for new and underexplored areas. Thirdly, the collaborative nature of our team, while beneficial for diverse perspectives, also introduced variability in data extraction decisions, which may have affected the consistency and comprehensiveness of the data synthesis. Fourthly and most importantly, only one of the 16 included articles has specifically focused on refugee IMGs. We had to fish through a large number of publications to identify a few that included (although did not focus on) Afghan and Arab refugee IMGs. Only this way were we able to scope the status quo of scholarship on this distinct subgroup of refugee IMGs. This posed a formidable challenge to our study: we had no choice but to deal with a very heterogeneous mixture of studies. In a scoping review, such a mixture means that the included studies had significant differences in their populations, methodologies, and outcomes measured. This made it difficult for us to reliably pull out data specifically related even to the overall population of interest, Afghan rIMGs and Arab rIMGs, let alone the particular subgroups of Afghan, Iraqi, Syrian, and Yemeni doctors. These limitations highlight the challenges associated with conducting scoping reviews on new and evolving topics.

5.2. Strengths

Our team’s knowledge of the subject matter, capability to effectively conduct comprehensive and iterative scoping reviews, focus on thorough literature searches, map existing literature, identify gaps, and synthesize relevant findings are key strengths. The team integrated Arksey and O’Malley’s framework and conducted multiple searches across different databases using advanced search techniques. Our team’s interdisciplinary nature also lends itself well to the thorough review and consideration of points presented in our selected articles. Another strength was integrating stakeholders’ experience, insights, and feedback from our team’s many years of experience working with stakeholders and the rIMG community. Lastly, our findings informed constructive recommendations that may lead to valuable paths forward in the field.

6. Conclusions

Given the heterogeneous mixture of both refugee and non-refugee IMGs in our included studies, it was not possible to perform separate analyses specifically for the Afghan and Arab rIMGs subgroups within the data, considering the limitations of the subgroup-specific available information. Subgroup analyses may be possible in future research with more standardized study designs in a systematic review. Nevertheless, we attempted a descriptive analysis to summarize the range of our findings on Afghan and Arab rIMGs across different studies.

The inconsistencies in the evaluation of Afghan rIMG credentials appear to be a major barrier to their relicensing in HICs, and this is the only major difference our review can identify between Afghan and Arab IMGs. All other indicators of barriers are more or less similar. Many Syrian rIMGs struggle with difficult cultural barriers and perform poorly on the English Language Testing. Muslim rIMGs, especially Afghans, struggle with Islamic moral and religious gendered norms, not condoning the performance of certain medical procedures on the opposite sex. Both Afghan and Arab rIMGs IMG refugees have pressing personal and family needs conflicting with career aspirations.

Coupled with unemployment and poverty, the traumatic stress of many rIMGs is worsened by the cultural obligation to remit money to family members in crisis in their home countries. While Germany and Sweden are expanding their medical personnel to include IMGs, they are nevertheless slow in supporting rIMGs in training, certification, and work settings. The implications of our findings are manifold: (a) rIMGs have the potential to lessen the burden of physician shortage in the US and other Western and European countries; (b) although varying widely across residency training programs and countries, there is a clear interest in engaging rIMGs in the medical relicensing process; (c) it is necessary for program directors to recognize the trauma, cultural gaps, and the post-resettlement hardships faced by rIMGs to inform more supportive reentry processes; (d) medical residency program directors in the US interested in recruiting rIMGs could find inspiration and practical lessons in the experience of several programs identified by this review; and (e) there is much room for improvement of the accreditation and evaluation of credentials, a less ambiguous and more streamlined process is necessary for ease, fairness, and rIMG professional inclusion.

Future qualitative research should engage all stakeholders (refugee IMGs, refugee community leaders, medical residency training program directors, etc.) in focus groups and/or in one-on-one semi-structured interviews to allow an in-depth exploration of some of the themes highlighted in this study. Lastly and importantly, future research should look specifically at Afghan and Arab rIMG barriers and facilitators of professional reentry, as they represent a large yet still understudied group of IMGs vulnerable to brain waste. Without more group-specific data, policy recommendations to support the professional reentry of Afghan and Arab rIMGs are bound to remain generic and weak.