International sore throat guidelines and international medical graduates: a mixed methods systematic review

Sore throats are common and one of the top ten reasons for seeing a doctor in New Zealand (NZ).¹ In the NZ European population, most sore throats have viral aetiology, are self-limiting, and resolve without the need for medical intervention.^2,3 In an estimated 10% of adult and 15–30% of paediatric cases, sore throats are a result of group A beta-haemolytic streptococcal (GABHS) infection.⁴ Acute rheumatic fever (ARF) is an auto immune multi-system disease that occurs as sequela to GABHS. Throughout the developed world ARF has all but disappeared. For example, a recent study reported in the British Medical Journal examined 14 610 adults for complications following an acute sore throat and failed to mention ARF.⁵ However in NZ, ARF remains a serious illness with high rates among Māori and Pasifika children compared with other children.⁶ Most cases of ARF are seen in the North Island, in poor socioeconomic areas. The rates of ARF in Māori and Pasifika have failed to reduce since the 1980s.⁷

NZ has the highest number of overseas trained doctors in the Organisation for Economic Development and Co-operation (OECD) countries, at 41%, nearly double the level of Australia.^8,9 These international medical graduates (IMGs), who often hail from countries where ARF has been virtually eradicated such as the UK, may not be aware of the continuing problem of ARF in NZ. Additionally there is a plethora of international guidelines that have been developed to inform sore throat management, many of which aim to decrease antibiotics use in settings of low ARF prevalence, unlike NZ. Some IMGs who work in primary health care or rural practice may be unaware of the NZ specific guidelines developed by the Heart Foundation for sore throat management in Māori and Pacifika people.

This article is guided by a mixed methods systematic review using a contingent methodology and starts with a review of international sore throat guidelines. Our thesis is that guidelines are country specific and many IMGs may be unaware of the problem of ARF in Māori and Pacifika people in NZ. There are no bridging programmes available for IMGs coming to work in primary care here. IMGs may be unaware that access to primary health care, and thus treatment of sore throats, is limited for many Māori and Pacifika people and that this may contribute to the failure of ARF reduction over the past three decades. The persistence of high rates of ARF in NZ is now receiving attention from policy makers. It is timely to explore the preparation for IMGs coming to work in NZ, particularly for IMGs working in general and rural practice.

We conducted a mixed methods review using a contingent methodology.¹⁰ Contingent methodologies were described by Sandelowski et al. as being one of three frameworks to conduct a mixed methods review.¹¹ The other two ways are segregated and integrated mixed method systematic reviews. A contingent methodology involves two or more systematic reviews that are conducted sequentially and based on the results of the initial synthesis (see Figure 1). They can use data from qualitative, quantitative or mixed methods studies. In our review the initial data collected pertained to the number of international sore throat guidelines and their key points. The subsequent review focused on a content analysis of studies referring to IMGs working in primary health care in NZ.

Figure 1. Mixed-method systematic review using a contingent methodology¹⁰

The review commenced with searching and appraising international guidelines written in English for sore throat management. After reviewing and synthesising guidelines published between November 2012 and February 2013, it became apparent that there were inconsistencies in guideline recommendations. These inconsistencies led us to theorise that IMGs may be unaware of the specific problem of ARF in NZ and may refer to guidelines from their home countries when practising medicine in NZ.

A systematic search of the literature pertaining to guidelines for sore throats was conducted. The databases accessed were Medline, Google Scholar, Trip Database, and NHS Evidence. Relevant references were retrieved from the reference lists of the guidelines. The search was limited to full text articles published in English January 2000 – December 2012. English language is mainly used in the NZ health system and therefore it was considered unnecessary to appraise guidelines in other languages. Keyword terms used were ‘guidelines’, ‘pharyngitis’, ‘sore throat’, ‘diagnosis’, ‘management’, ‘antibiotic therapy’, and ‘streptococcus’.

The initial search of quantitative data relating to clinical guidelines in sore throat management elicited 26 suitable guidelines. Following analysis of the guidelines, we conducted a search of Medline, Embase, Google Scholar and Scopus using the search terms ‘international medical graduates’, ‘foreign medical graduates’ ‘overseas trained doctors’, ‘New Zealand’, ‘general practice’, ‘family practice’ ‘rural practice’. This search was limited to full text, English language articles published from January 2000 – December 2013. Reference lists were appraised to identify policy documents and literature from medical professional bodies. The New Zealand Ministry of Health and Medical Council of websites were explored for information on IMGs.

Only eight articles were identified following this search and so ‘Australia’ was added as a search term due to its close ties with NZ’s medical system via the Trans-Tasman agreement. Adding ‘Australia’ as an additional search term elicited a further four articles.

KH and EW appraised all of the guidelines and used the AGREE Collaboration’s criteria for high quality clinical practice guidelines¹² (Box 1). Twenty guidelines met these criteria. The data were subject to content analysis and then organised by EW and KH into key themes.

Quality reporting standards are increasingly expected in health services research. The recently developed RAMESES (Realist and Meta-review Evidence Synthesis: Evolving Standards) publication standard was followed.¹³ The authors of this standard emphasise the importance of transparency in reporting the results of a realist or meta-review evidence synthesis. The authors considered the RAMESES standard an appropriate guide to convey the transparent process involved in the selection of data.

Figure 2 illustrates the RAMESES process that KH and EW used to determine data selection from 59 articles initially retrieved during the second search. Only 12 articles referred to IMGs working in general or rural practice in NZ or Australia and all of these were appraised and included in a content analysis. A further three articles were sourced following scrutiny of the reference lists of the original 12 articles. Additionally the websites of NZ’s Ministry of Health, NZ Medical Council and the OECD were accessed.

Figure 2. Flow diagram illustrating RAMESES search process

From analysis of data produced by the first search, the first theme refers to discrepancies in guideline recommendations. The subsequent three themes were constructed following the second search. All of the themes were reviewed by BA. The themes form the following four sub-headings:

See Table 1 for the main recommendations and major findings for each of the 20 guidelines. Only three of the five guidelines from Europe specifically refer to ARF. The English guideline does not mention ARF and the guideline from Scotland stipulates that antibiotics should not be prescribed to prevent ARF. This guidance contradicts NZ’s algorithm for sore throat management.¹⁴ Of the five guidelines from North America, only four mention ARF. There were eight guidelines from the Asia Pacific region and, excluding three guidelines from NZ, only two of the remaining five discussed ARF. One of the Australian publications stated that focused programmes of early GAS pharyngitis diagnosis and management in populations at high risk of ARF have not yet been shown to translate to a significant reduction in ARF incidence. The single guideline from South Africa does make reference to ARF. It was the discrepancy in guideline recommendations and their potential influence on the knowledge/attitudes and skills of IMGs that prompted the authors to consider the role of IMGs in primary health care in NZ.

Table 1. Main recommendations from guidelines

Migration of medical graduates is not a new phenomenon. The first half of the 20^th Century saw doctors moving from developed countries to developing countries (low and middle income), whereas the latter part of the 20^th Century saw a reversal of the flow, from developing countries to developed ones. This direction of movement of doctors from low and middle income countries to high income countries caused concern internationally.¹⁵ There has also been substantial migration of UK trained doctors to Australia, Canada and the USA, unmatched by a flow from these three countries to the UK.¹⁵ The latest Medical Council of NZ workforce survey from data collected to comply with the Health Practitioners Competency Act 2003 showed that IMGs were 41.4% of medical practitioners registered in NZ. This percentage increased from 34% in 2003.¹⁶ Of the 14 countries belonging to the OECD, NZ has the second largest number of registered IMGs: only Ireland has more.⁹

One study of 282 UK trained doctors working in NZ showed that only one third had intended to stay when they first left the UK but by the time of the study’s survey, 9 out of 10 intended to stay ‘probably’ or ‘definitely’.¹⁵ These doctors may have initially been ‘medical tourists’ who managed to acquire permanent residence in New Zealand.¹⁷ Garces-Ozanne et al.¹⁸ examined the mobility of medical practitioners throughout NZ during 2000-2008 using data obtained from the Medical Council of New Zealand’s register of physicians. In 2008 vocationally trained general practitioners (GPs) who were reported as IMGs from English speaking (developed countries) comprised 30% of the total number of vocationally trained GPs in NZ. Doctors reported as ‘trained elsewhere’ comprised 25% of the GP workforce (there may be duplicates in the reporting of where IMGs trained). IMGs tended to practice in minor urban and rural areas with socio-economically deprived populations.

Lillis et al.¹⁶ suggested that many IMGs have experienced difficulty integrating into the NZ workforce but there has been little formal research examining the reasons for this. Their qualitative study identified ‘work issues’ as a key theme for successful integration into the NZ hospital system. Participants noted discrepancies between the culture of medicine in their country of origin and aspects of working life in NZ. Hospital staff had high expectations of IMGs, requiring them to function independently and competently as soon as they started work. One small NZ study investigating the opinions of hospital based doctors and nurses on the training needs of IMGs found potential areas for improvement in skills including communication with patients, families and health professionals, documentation, knowledge of the health system and some aspects of patient management.¹⁹ Australian researchers cited culture shock as having an adverse effect on the mental and physical health of IMGs, leading to poor general well-being and psychosomatic symptoms.²⁰ Other Australian studies cited communication as a key problem for IMGs.^21–23 Different accents and cultural norms as well as colloquial language and idioms cause difficulty for IMGs. Additionally when the profession investigates poor practice, there has been an association with professional isolation and a lack of insight into behaviour.²⁴ Hawken²⁰ suggests that tools should be developed to identify IMGs most able to adapt and change their behaviours to work in NZ.

Between 2001 and 2004 NZ offered re-training programmes for IMGs. These courses have been discontinued and have not been replaced²⁵ as their purpose was specifically to redress an error regarding registration of a group of migrant doctors in the 1990s.²⁰ Many of NZ’s practising GPs who are also IMGs are not vocationally registered. It has been suggested that vocational registration for IMGs is too slow and an onerous under-taking.¹⁷ Kearns et al.²⁶ investigated factors that keep doctors ‘in place’ and stop their departure from practice in rural NZ. Their in-depth interviews with nine IMGs highlighted the difficulty of attending continuing medical education sessions provided by district health boards and primary health organisations. Reasons for non-attendance were travel time, costs, and time away from their practice.

One of the fundamental tenets of clinical governance is the use of evidence-based information.²⁷ Clinical guidelines are an important source of information for clinicians in ensuring best practice in patient care. Our review has highlighted the discrepancies in international guidelines for sore throat management. IMGs tend to practice in New Zealand in minor urban and rural areas with less affluent populations who are more at risk of contracting ARF.^6,18 Furthermore they may have difficulty attending CME sessions.²⁶ Additionally, as vocational registration is meaningful from a patient-safety perspective, it is concerning that many IMGs who work as GPs have not met this standard.¹⁷ To gain registration in NZ, IMGs have to pass the NZRex examination that does include a cultural competency component. However, IMGs, may never be exposed to patients at risk of contracting ARF in an examination scenario (personal communication). Bridging programmes are not consistently available for IMGs.

The strength of this review is that it followed the AGREE and RAMESES statements which are both recognised as quality consensus tools providing transparency in data appraisal. Transparency helps readers decide for themselves if reviewer judgements made are reasonable, both for the topic and from a methodological perspective. Additionally, findings from the current research, notably that NZ is heavily reliant on IMGs and that guidelines for sore throat management are country specific, are plausible. A limitation is that the themes developed from data were constructed by KH, EW and BA and other researchers may have developed alternative themes.

This review has highlighted that NZ has a unique problem in the developed world with respect to ARF management: IMGs may lack this knowledge and so not adhere to NZ specific guidelines for sore throat management. As NZ is heavily reliant on IMGs, it is timely that their knowledge and actions regarding care of Māori and Pacifika people is investigated. There is a need for research to gauge the knowledge of IMGs who practice as GPs regarding the NZ specific guidelines for sore throat management. Urgent action is needed in NZ to reduce the levels of ARF in Māori and Pacifika peoples.