Ian Powell – New Zealand loses two-thirds of recruited overseas trained medical specialists within five years!

What a headline: ‘Two thirds of overseas-trained medical specialists leave again in less than five years’. It is hard to beat it for dramatic effect especially as it is right on the mark.

Aotearoa New Zealand’s health system depends on international medical graduates (IMGs) who are doctors who have obtained their first medical degree overseas.

In fact, IMGs make up nearly half of New Zealand’s registered medical workforce (42.4% according to Medical Council data) which is one of the highest proportions in the OECD.

What does this dramatic headline tell us about the state of Aotearoa New Zealand’s health system?

Is it fiscal irresponsibility, poor pay or working conditions (or both), poor orientation and induction, a destabilised and rundown health system, or our small size and relative geographic isolation?

Intuitively it is the cumulative effect of all of these with the first being one of the consequences of the rest.

Eye-catching

The eye-catching heading belonged to a Radio New Zealand item by its health correspondent Kate Green (16 September): Revolving door of recruited overseas-trained specialist physicians.

Kate Green, Radio NZ health correspondent

The item is a little confusing in its use of the term ‘medical specialists’. This risks the inadvertent implication that all medical specialists, in the New Zealand context, are physicians. Not so.

Physicians are medical specialists who diagnose and manage complex medical conditions of adults, infants, children and adolescents. This includes respiratory, oncology, paediatrics, addictions and sexual health.

Other medical specialists include those trained in surgery, emergency medicine, psychiatry, radiology, pathology, public health, and ophthalmology. As with physicians, each has their own specialty-specific scope of practice and professional college (in most cases shared with Australia).

IMGs feel devalued and unsupported

Kate Green reports the Australasian College of Physicians stating that whereas New Zealand has 44 actively practising specialist physicians for every 100,000 people, Australia has 50% more; 66 per 100,000 people.

Associate Professor Janak de Zoysa is the President of the NZ Committee of the Australasian College of Physicians

It is hardly surprising that Associate Professor Janak de Zoysa would say to Green that many physicians “were exhausted and burnt out.”

It is also hardly surprising that, according to the College, only 28% of IMG physicians remained in New Zealand after five years, compared with 85% of doctors trained locally.

However, it is not just stressful working conditions. According to the College, only half receive a formal induction into the health system, and a mere 3% reported receiving any meaningful orientation.

In Dr de Zoysa’s words:

They [IMGs] don’t feel valued and they don’t feel supported.

If we can make that investment in people and hang on to them, that’s 30 years of a trained specialist who will provide care to literally thousands of people.

But there is another factor; poor remuneration. Associate Professor de Zoysa describes his own situation:

I’ve been working as an internal medicine specialist for over 20 years and my salary is less than a junior consultant starting salary in Australia.

For context, in my final year (2019) as Executive Director of the Association of Salaried Medical Specialists (ASMS), I commissioned an independent investigation by BERL economics consultancy into the core salary gap for salaried specialists between New Zealand and Australia.

It revealed a huge salary gap the wrong way of over 60% (most likely widened since then). This contrasts with the around 25-30% pay gap for workforces generally.

It also excludes particularly high employer superannuation contributions and the lucrative salary sacrifice taxation system.

Hard facts on retention loss of IMGs

The most authoritative data on the medical force comes from the regulatory authority for doctors, the Medical Council, which publishes annual survey-based workforce reports.

Its latest survey results, with a highly credible 97% response rate, were published in August in its Medical Workforce Report August): 2026 medical workforce report.

Medical Council data confirms high IMG retention loss

Its results are consistent with the above-discussed assessment of the physician workforce by its professional college.

The report confirms that most IMGs (including general practitioners) do not stay in Aotearoa for long. Just over 40% leave after one year; 60% after two years; and 75% after 10 years.

This contrasts dramatically with the retention loss for New Zealand medical graduates – 1% one year after registration; 5% after two years; and 12% after three years.

IMG experiences

ASMS has also published in May the results of its survey of its members titled Recruited globally, neglected locally (equally eye-catching as the opening RNZ headline): IMG experiences.

There are statistical limitations compared with the Medical Council’s workforce report; confined to ASMS members and a low response rate of 29.5%.

However, it was conducted for a different, including more qualitative, purpose and scope. The value is its explanatory insights for the high retention loss of IMGs.

The key findings of the ASMS survey were:

• 5.3% of New Zealand medical graduates and 17.1% of IMGs are likely to go overseas to work and settle;
• IMGs long-term intentions to remain in Aotearoa are shaped by remuneration (31.2%; dissatisfaction with remuneration has increased significantly over the years), workload issues (21.5%), and quality of managerial relationships (17.5%);
• IMGs are faced with the challenges of distance from family and friends (52.2%), health system differences (37.6%), and cost of living (29.9%);
• only 3.1% of IMGs received an orientation to our health system on arrival;
• only 24.7% of IMGs received cultural competency or cultural safety training; and
• only 50.9% of IMGs received a formal induction process that included job expectations, IT systems, and explanations of electronic records.

The report (p.37) also infers that “…remuneration is the most important factor to [IMGs] by a substantial margin.” Further, remuneration satisfaction is declining among IMGs (similarly with New Zealand graduates).

An elephant in the room

Given the importance of remuneration as a contributor to the high retention loss of IMGs, it is surprising that ASMS did not include reference to the above-mentioned massive core salary gap with Australia in its otherwise insightful publication.

Massive salary gap with Australia is a large elephant in the room

This is particularly so given the proximity of the two countries and that they share the same medical training schemes.

While there can be complications for medical registration when IMGs migrate directly to New Zealand or Australia (largely dependent on the health system they came from), when registered here, it is not complicated to then go from New Zealand to Australia. Likewise for the other way around except that this is a rare occurrence.

In fact, in its public commentary on its collective agreement negotiations with Health New Zealand that have included strike actions, this has barely rated a mention; an occasional aside at best. ASMS would be well advised to have a good think about this.

Irresponsibility of recruiting doctors without an intention to keep them

Dr Katie Stuart is a specialist physician who came to New Zealand from the United States in 2017. On 21 September The Press published her thoughtful but unfortunately paywalled opinion piece: Can’t keep recruiting doctors who we have no intention of keeping.

Much of her focus is on the lack of orientation, induction and mentoring. She is consistent with the observations of both the College of Physicians and ASMS.

She also noted the high turnover and shortages of specialists. This workforce vulnerability does suggest an interesting question.

Had Dr Stuart came to New Zealand 10 years earlier when there was more workforce stability and a much smaller salary gap with Australia, would there have been more staff support to provide the level of orientation, induction and mentoring that IMGs desperately need.

While there is poor pay, working conditions, orientation, induction, mentoring and a continuing destabilised and rundownhealth system, Aotearoa’s small size and relative geographic isolation guarantees that it will continue to recruit large numbers of overseas-trained medical specialists who don’t stay.

This is not just very poor health system policy; it is fiscal irresponsibility at its worst.