…in the initial days they filled the jobs when nobody else would take it. And they tried to copy the best leaders. And implement changes in their own patch like the best leaders had done. So there were geriatricians in hospitals where facilities were so poor I probably wouldn’t work in those even today. And so that’s one of the things that they went to the areas where local doctors didn’t go. And they filled those jobs where local doctors weren’t interested. It wasn’t that the local doctors didn’t get those jobs. They weren’t interested in those jobs (LO22).

This quote comes from an interview with a consultant physician in geriatric medicine, almost retired, and working at a teaching hospital. He arrived in the UK in 1973, hoping to do postgraduate work and to develop his medical career as a physician. He had been warned that cardiology and gastroenterology were too competitive and so ended up applying for jobs in geriatrics, a specialty he had not even heard of before he came to the UK. Similarly, the London hospitals were popular so he ‘looked at the map’ and made his choice on that basis, ending up two hundred miles away in a place which ‘didn’t mean anything to me’ but which answered first. Forty years later he is well known in the specialty and has an established reputation in the region where he works for his clinical work, his leadership in education and training, and in his local community generally.

He is one of sixty working and retired South Asian geriatricians being interviewed for the ESRC-funded project: ‘Overseas trained South Asian geriatricians and the development of geriatric medicine’ 1. This project has been designed to complement the archive of over 50 interviews with the pioneers of geriatric medicine, carried out by Professor Margot Jefferys and her colleagues in 1990-1 (Jefferys, 2000). Geriatric medicine is noted for having a high proportion of overseas trained doctors (Smith, 1980, p. 18; Oliver, 2008). Figures show, for example, that 22 per cent of all geriatric consultants appointed between 1964 and 2001 were non-white and had trained outside the UK, compared to 14.1 per cent of all consultants in the NHS (Goldacre et al., 2004). One key aim of our research is to investigate to what extent these South-Asian doctors not only helped the NHS to care for older people but, through their membership and leadership within the British Geriatric Society as well as other medical organisations, also contributed to shaping the discipline in the UK. The Jefferys’ study included only one South Asian doctor. This new study is making good that gap and recording, for the first time, the experiences of a group of doctors racialised as ‘other’ and working within a marginalised medical specialty: the care of older people. Thus, it explores the dynamic interplay between ethnic and professional identities within a changing labour market for a relatively privileged group of highly skilled migrants. By looking at the contributions of a generation of South Asian geriatricians we also move away from seeing ethnicity as a marker of welfare receivers alone. Here are a group of welfare providers who not only provide welfare but also shape the nature and content of welfare for generations of frail older people.

Of the target sample of 60 interviews, twenty-three, averaging two hours each in length have so far been completed. Of these, fourteen have been transcribed. This paper draws on those transcribed interviews, a group which includes doctors trained in India, Sri Lanka, Pakistan and Burma, ranging in age between 40 and 75 arriving in the UK from the 1960s onwards. The sample will eventually include doctors whose careers ended at different points in the medical hierarchy. However, the interviewees whose accounts we draw upon for this paper all happen to be hospital consultants, some also holding academic posts such as that of professor.

The interviewees are being recruited through networks of overseas doctors (British Association of Physicians of Indian Origin for example), the British Geriatrics Society (the professional association of geriatricians) and through snowballing as the project progresses. The interview schedule uses a life history approach, asking participants to talk about their childhood, upbringing, education at school and college and subsequent training and careers and family life in their home countries and after arrival in the UK. The doctors are asked about their reasons for migration to UK, arrival and subsequent career progression in the UK with a focus on opportunities, barriers and sources of support. The interview schedule also includes questions which invite reflection on their time in the UK including their experience of racism and their views of work in the geriatric specialty.

These doctors, from their own accounts, felt drawn to the UK, rather than the USA, and in South Asia were already part of a socio-cognitive community for whom markers of participation in the UK labour market were central to notions of career progression. Migration to the UK for the purpose of training, gaining membership of prestigious UK Royal Colleges (MRCP etc.) has long been embedded in South Asian doctors’ professional cultures (Raghuram, forthcoming). All the interviewees were taught in medical schools by lecturers who had undergone some form of training in the UK. In this context upgrading and validating skills through training at one of the UK Royal Colleges was seen as crucial to being recognised as a good doctor. Thus, the doctors’ mobility was already embedded in a network of professional development which valued temporary movement to the UK. 

The first interviews are already providing evidence which points to new and more informed ways of understanding not only the lives and careers of migrant doctors in the UK, but also the development of the geriatric specialty. So, for example, the doctors interviewed highlight their role in shaping a discipline, through the specialist networks they entered, the sub-specialisms they developed, and the organisational and administrative leadership they showed in managing the health of frail older people. They describe life courses constrained by established patterns of migration and post-colonial career development but also by choice and opportunity. Thus, we hear not only of the ways that they have responded to pre perceived exclusion of migrant doctors from certain medical career paths in the UK (Esmail & Carnall, 1997; Decker, 2001; Esmail, 2007), but also of the role of earlier path-finding migrants, the nature of patronage in the twentieth century NHS and how geriatrics itself, as an emergent specialty offered opportunities to doctors who were prepared to take less conventional routes to qualification.

The accounts that the South Asian doctors give of their entry into the specialty are in many ways similar to those given to Margot Jefferys. Doctors whose careers were interrupted by service in World War Two or who themselves were part of an earlier refugee migration, or who had taken less conventional or prestigious medical education routes also found that geriatric medicine provided a space for career development. Cyril Cohen’s account is not unusual:

"That was the turning point, in 1952. We'd all been told that 'Yes, you're doing your National Service. Don't worry there'll be jobs, there'll be jobs', but, of course, after the war there was a large number of very senior experienced doctors who couldn't get jobs, and there was mass migration all over the world. And it was very difficult to get a job. And I went to Withington Hospital where there were a number of house physician jobs available and didn't get any.

And then someone came out from the Boardroom and said 'Is anyone interested in geriatrics?' - It was called geriatrics then, in other words now it had got a derogatory meaning. And I said 'What is it?' and he said 'Well, it's like medicine' and I said 'Well, yes. Anything for a job'. And I went in and I was asked what did I know about geriatrics and I said 'Nothing', I don't think I'd heard the word. I said 'Is it a facility where old people go to die?' and the consultant, bless his cotton socks, he didn't bridle or his hair didn't get ruffled, he just sort of smiled weakly and explained. And this was Joe Greenwood, the Consultant. And I said 'Yes, I'd be delighted to have the job', especially when I heard it was at senior house officer level, not house physician. I'd never been a house physician, just a house surgeon. So it was more money." (Jefferys’ interview 207 British library catalogue no: C512/10/01, /f3276)

This project brings together insights from Jefferys’ data set from those emerging from our current interviews. For instance, the same tone of identifying a career pathway in the context of restrictive opportunities was also faced by one of our interviewees. Arriving in 1966 he discovered:

" I must mention here at that time discrimination was much much more rife than now. I will not say that discrimination has gone away from NHS even now really, even now, even today, but it was much much more pressing, yeah, at that time. By that we meant clearly that if anyone with a local, with a native, from the native population, you know, anyone from that, if they come to any interview for a job of course you will never get it really. It was always either pre arranged, pre booked, or even booked at that stage. The same thing happens in exams, you know, we were treated slightly more fairly in exams compared to the natives and compared to how we were treated in NHS really. Because there was a tradition of (inaudible), in my case the Indian students coming over and passing the exam and going back to fifty, sixty years really. But there was no tradition, not much tradition, of Indians coming over and working in the NHS at that time" (L031).

Whilst these migrant doctors encountered discriminatory practices many were able to resist marginalisation through a combination of networking and patronage that were the key to professional development in the NHS. An important step for most was to find a locum position in which to gain experience and build a reputation:

"Then I met a friend who came down one day, he used to work here in UK and so I talked to him about that, what is the opportunities for training in the UK. He said “They are not great” (laughs) “But if you are lucky probably you may start in some place, get in there” ... So he helped me to contact the General Medical Council for my registration, at least I had some contact, some direction to get the registration. Once I was registered…he said that “I could be able to arrange a locum job for you” and so that was in St Helen’s Hospital in Liverpool. So he arranged a short locum for me there, for a week or two or something "(L025).

For all informants, building a career in geriatrics was dependent on being recognised as someone with potential in a fast developing area:

"…I was in a way pressurised to take a decision on either changing my career path and the speciality or go into staff grade. And this consultant who I was working in this Great Yarmouth was totally against me going into a staff grade job. He said – I don’t know how much he meant it – he said to me “You are too good to become a staff grade and it is a dead end, you will be alright for about one year, two years, three years, after which you will get bored. You may think endoscopy is exciting now. Four years down the line if you are doing the same….it will be irritating and you won’t find a huge amount of findings in this country... So over time it would become very uninteresting. I strongly suggest that you consider yourself a physician consultant in DGH and not worry about speciality. The best speciality would be geriatrics because there’s lots of …” I think at that time they had quite a lot of people applying for SPR in geriatrics because the (inaudible) had come. Many of the British graduates didn’t apply as far as I know, to become a SPR in geriatrics because they thought it wasn’t a sexy speciality for them. So there were lots of posts coming up." (L026)

This quote illustrates how migrants, like other pioneers in geriatrics, resisted marginalisation by taking advantage of gaps in the labour market at particular times and in particular places. At this time the nature of geriatric was changing dramatically with an increasing emphasis on acute medicine and integration with other aspects of general medicine. In this situation many of the informants were given the scope within their locality to recast geriatrics in the image of the area of general medicine from which they had been excluded.

By the time members of our sample were finding employment in the NHS, the geriatric specialty was generally well recognised (Evans, 1997; Thane, 2000; Bridgen, 2001; Denham, 2006) and there was a suite of work by doctors such as Cyril Cohen on which the South Asian doctors could build. Some found themselves working in the teams built by pioneers in Manchester and the West Midlands, others, at a later stage, and working through the British Geriatrics Society, were able to build up their own centres of good practice. Their accounts illustrate the contribution which overseas trained doctors from the sub-continent made to the development of geriatrics, with careers spanning the 1960s to the present day, they have been witness to as well as architects of change:

"But when I came and I had said at the interview that my idea of practising geriatric medicine would be to provide a holistic sort of comprehensive service to the elderly. That means the acute; you know, plus rehabilitation, out patient, follow up, day hospital, everything. But including acute. So within ten months of me joining the department from an old fashioned department went straight to acute service from 1 st of December 1982, sorry, 1 st of October 1982. So it went total acute. And we started accepting all medical emergencies in the elderly patient as long as the patient was over the age" (L027).

In conclusion, we can say that first results from interviews with South Asian geriatricians show many parallels with the career development of the pioneers of geriatric medicine. Entry to the specialty tended to be by chance, or seized as a chance to progress with fewer obstacles. Having entered the specialty there was space to innovate and to contribute to developing the profile of geriatric medicine and to directly influence the quality of medical care that UK older people were receiving in the mid to late twentieth century. Their accounts also reveal much about recruitment practices for overseas-trained doctors, and indeed for junior doctors generally, in the NHS, with evidence that racism and localism played a large part in career development. From these accounts, taking the migrant journey in medicine was not always an easy choice to have made and geriatrics was not the destination they would have chosen, even known of, at the outset. Once there, however, they have made their mark on the specialty and undoubtedly contributed in a major way to its improved reputation within medicine and UK society generally.

References

Bridgen, P. (2001). Hospitals, geriatric medicine and the long-term care of elderly people. Social History of Medicine, 14, 507-23.

Decker, K. (2001). Overseas doctors: Past and present. In N. Coker (Ed). Racism in medicine: An agenda for change (pp 25-47). London: King's Fund.

Denham, M. (2006). The surveys of the Birmingham chronic sick hospitals, 1948-1960s. Social History of Medicine, 19 (2), 279-293.

Esmail, A. (2007). Asian doctors in the NHS: Service and betrayal. British Journal of General Practice , October, 827-834.

Esmail, A. & Carnall, D. (1997). Tackling racism in the NHS. British Medical Journal , 314, 618.

Evans, J. (1997). Geriatric medicine: A brief history. British Medical Journal, 315, 1075- 1077.

Goldacre, M. Davidson, J. and Lambert, T. (2004). Country of qualification, ethnic origin of UK doctors: Database and survey results. British Medical Journal, 329, 597.

Jefferys, M. (2000). Recollections of the pioneers of the geriatric medicine specialty. In J. Bornat, R. Perks, J. Walmsley, & P. Thompson (Eds.), Oral history, health and welfare (pp 75-97). London: Routledge.

Oliver, D. (2008). The British Geriatrics Society at 60. Generations Review, 18, (1). Available online at: http://www.britishgerontology.org/08newsletter1/education_careers.asp [Accessed 25 May, 2008].

Raghuram, P. (forthcoming). Caring about the brain drain in a postcolonial World. Geoforum.

Smith, D. J. (1980). Overseas doctors in the National Health Service. London: Policy Studies Institute.

Thane, P. (2000). Old age in English history: Past experiences, present issues. Oxford: Oxford University Press.

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1 ‘Overseas-trained South Asian doctors and the development of geriatric medicine’, ESRC grant RES-062-23-0514. http://www.open.ac.uk/hsc/research/research-projects/geriatric-medicine/home.php

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