Table 6 Barriers to and facilitating aspects and strategies for entry into and advancement within the medical labour market in Sweden

Originates from another country and/or has a medical degree from abroad

Origin from another country was a perceived reason by 16% of the respondents (n = 283) for having one’s competence undervalued during the job-seeking process compared to physicians with a medical degree from Sweden.

‘They have said it straight out in the interview without knowing or knowing what knowledge I have. On several occasions I heard prejudices about the country I was trained in’.

Others did not believe that their medical knowledge was enough, which was a perceived reason for having competence undervalued by 11% of the respondents (n = 283). One respondent wrote: “I worked as a [names a specialty] for [XX] years, unfortunately my experience became ‘zero’”.

To have a medical degree from abroad was a perceived reason for 6% of the respondents for having their competence undervalued.

‘Worked as a junior doctor and had been promised a mandatory medical internship; however, physicians who had never worked as junior doctors got their mandatory medical internship before me, probably since they were educated in Sweden/EU’.

‘There is many/almost everyone who does not trust foreign physicians’.

‘Got to hear from a medical director at a geriatric clinic where I applied for a job that we know nothing, can do nothing, and that we are burden on the Swedish system, and that they do not even want to meet a doctor like us’.

Not all respondents were born abroad, but may have moved during childhood and then returned

‘It has been an advantage being born and raised in Sweden and speaking Swedish fluently, in comparison to CPP peers’.

Applying for Swedish citizenship

As a strategy to increase job opportunities, 11% of the respondents had applied for Swedish citizenship.

Having experience from another country

‘My experience from my home country helped me a lot’.

Having another ethnicity and/or religion or other belief

Having another ethnicity and/or having another religion or other belief is not the same thing, but can be connected in how people perceive each other.

Of the respondents, 20% perceived that they had been disfavoured related to discrimination by having another ethnicity, and 7% perceived that they had been disfavoured related to discrimination by having another religion or other beliefs.

‘Regarding Muslims and Arabs, they think we have a bad view on women’.

‘I wear a veil’.

Having a different name

A name might imply one’s origin.

‘Personally, I believe that foreign names and ages can affect the application. I experienced that’.

‘Arabic name is enough to get a no’.

Some respondents, 2% (n = 7), had changed their name to a Swedish-sounding name as a strategy for increasing opportunities to be employed.

Another strategy: ‘I erased [name] from my name’.

Insufficient language skills

To not speak Swedish good enough was mentioned by 5% as one reason for having one’s competence valued less than the competence of physicians educated in Sweden.

‘Got several who replied that I need Swedish knowledge even if my email, CV and everything is written in Swedish and they had never talked to me on the phone’

Learning the Swedish language

Learning the Swedish language was mentioned by respondents as a facilitating aspect.

‘I got my jobs because I did not have a strong accent and all of my interviews have gone well due to that’.

Strategies used to learn the language:

*Listening to audiobooks

*Reading a lot in Swedish

*Speaking with Swedish people in general

*Using language-training apps

*Participating in Swedish language courses

*Work

Of those who had a position as a physician, 50% perceived that speaking Swedish to Swedes was a very useful aspect that had increased opportunities for finding work as a physician in Sweden. Being married to a Swede was mentioned by one respondent as a facilitating aspect in learning the language, as they speak Swedish at home. The same respondent also mentioned that being married to a Swede had also increased possibilities to integrate into Swedish society.

In Sweden, different associations sponsor language cafés where migrants meet and speak, have coffee or tea with the aim of learning the Swedish language. Respondents had not participated in these events to a great extent, and most who had participated did not think of them as valuable for finding work.

Swedish language apps and apps with medical terminology and knowledge had not been used to any great extent, and respondents who had used these kinds of apps in general did not perceive them as useful in getting jobs.

Having the wrong age

It can be assumed that physicians from outside the EU/EEA in general are older than Swedish graduates when they compete for the mandatory medical internship and other positions in the medical field, such as specialty training positions.

Of the respondents, 8% perceived that they had been disfavoured related to discrimination based on age.

‘Due to high age, they do not want to give [mandatory medical internship]’.

Respondents also mentioned that it is more difficult to advance to specific specialties due to being too old.

Respondents’ waiting time for the MMI might be related to their age. Respondents with shorter waiting times were slightly younger:

10 months or less of waiting time (n = 59): 37 years

11 months or more of waiting time (n = 120): 41 years

Having the wrong gender

Of the respondents, 2% perceived that they had been disfavoured related to the discrimination based on gender.

Of those who had perceived themselves to be disfavoured due to gender, the majority were women (13 of 17).

‘They asked me about children and how many children I planned’.

In comparison to all respondents, and regarding the mandatory medical internship, men were slightly over-represented in beginning their MMI quicker after having completed route 1 or route 2 (CPP) than women:

10 months or less of waiting time (n = 59): 59% men/41% women

11 months or more of waiting time (n = 120): 44% men/56% women

Lacking work experiences and work references from work in Sweden

Lacking work experience was a perceived reason by 18% of the respondents (n = 283) for having one’s competence undervalued during the job-seeking process.

‘I was told from someone who sits on HR at an employer (which I did not apply for) that job applications from foreign doctors are put in a separate folder which is different from Swedish educated, as they prefer doctors that are experienced in Swedish healthcare’.

‘Not familiar with routines, the system’.

‘Judgmental employers who will not give foreign physicians without any experience from the Swedish medical labour market’.

‘Employers want to hire physicians with experience of Swedish healthcare’.

Lacking work references was a perceived reason by 13% of the respondents (n = 283) for having one’s competence undervalued during the job-seeking process.

Work in the Swedish healthcare and/or medical field

Before the CPP havingworked in the Swedish healthcare and/or medical field as, for example, an assistant nurse, nurse or physician assistant

This was in order to:

*Learn the language

*Learn and/or understand how the routines and system in Swedish healthcare work

*Develop contacts

*Get into or in touch with the healthcare sector

*Demonstrate skills

*Develop work references by showing competence during work before the CPP or during CPP internship.

*Have many work recommendations from different sites.

Regarding work in Swedish healthcare, as physicians in different positions or as other types of healthcare staff, respondents mentioned that they have struggled, taking difficult jobs, working hard, sometimes in uncomfortable working hours, and others have been on call at all times, taking jobs with a low salary in a specialty in which they preferred not to work.

Taking a job when over-qualified for it or with a lower salary

Of the respondents, 20% had taken a job beneath their qualifications.

‘It was quite easy to get a job at a healthcare centre since there is always missing physicians’.

‘Took the first job offered and accepted a very low salary in a specialty which I do not like’.

Doing research was mentioned by some respondents as an aspect that had increased their opportunities to get a job as a physician in Sweden. However, another MP had left work as a researcher in favour of an under-qualified job in the healthcare sector just to be able to work as a physician later on.

Positive approach

Respondents also mentioned that one needs to be open-minded to new knowledge, be flexible, positive, nice and humble to increase the possibilities to get a job. Also mentioned was that one should adjust to society and not listen to those complaining about the system.

Lacking contacts within the medical labour market

To lack contacts is a very common barrier in the comments; some examples:

‘I just sent my CV as I did not know that in Sweden you must have either contacts or recommendations, which I am not used to from my home country’.

‘It is difficult to get a job if you do not have any contact in healthcare’.

‘I had no contacts with the clinics which I applied for’.

One respondent brought up the topic of nepotism, friendship corruption and bias.

Having or developing contacts with

*Employers, developed during work before the CPP

*Workplaces, developed during the CPP internship

*CPP peers, developed during the CPP

*Family and relatives

*Friends

*Peers from the country of origin

*Mentors

*Having a personal network of Swedes

Contacts developed during the CPP were by more than one half of respondents thought to have made it easier for them to get a job as a physician in Sweden: partly, much or to a very much extent (n = 236).

‘Everyone who has contacts gets jobs faster. There are a large group of physicians from the same country [mentions some countries] that help each other a lot and give each other lots of information that others do not get’.

Strategies to find work without developed contacts

‘Sent email to all healthcare centres within [distance] from [city] to receive my first temporary post as a junior doctor’.

‘Visited the employer at his workplace as a drop in and then either booked time or had the opportunity to show my qualifications / grades and presented myself as a person, and it has worked well for me and I got a job fast – 3 weeks after my application –but I also could start earlier if I wanted to’.

“Searched work actively / went to work to ‘mingle’ before the interview”.

‘Actively contacted loads of employers in different specialties’.

High competition in the labour market regarding the mandatory medical internship, in certain parts of the country (cities) and for advancement within the labour market regarding some specialties

Of the respondents, 70% lived in a big/bigger city in Sweden.

Not being able to move due to family was mentioned by some respondents as a barrier to the labour market. For 15% (41, n = 269), children living at home affected possibilities or willingness to move; for 29%, children affected to a great extent; and for 19%, partly. For 50% of the respondents, a partner affected the possibility or willingness to move to either a great extent or completely.

To move or commute

‘Aimed at work outside the city, in a rural area’.

‘I applied for work everywhere in [region]. I got a call for interviews from some clinics but got my first temporary position far from my home town. Despite young children at home, I accepted it’.

As a strategy to increase job opportunities, 37% of the respondents had applied for a job outside their hometown.

‘I worked in 3 different towns before I at last got an MMI’.

Of the respondents having or who had had a mandatory medical internship position (n = 179), 36% moved for it. Of those who moved (n = 66 of 156), 36% were women and 64% were men.

Change specialty

Of the respondents, 19% had changed specialties to increase the opportunities for getting a job.

Administrative barriers

Respondent mentioned:

Lack of/or insufficient

*Information about the recertification process

*Clinical supervisors during different positions

*Medical internships (both before the CPP and the mandatory positions after the CPP)

*Cooperation between different authorities (such as the Public Employment Service, migration board, universities and other labour office programmes).

*Education positions at CPP

The time it takes before being able to work as a physician in Sweden is mentioned by respondents. For example: ‘If I could have gotten help with the language and a spot at the CPP directly, then I would not have been lost for 5 years’.

Also mentioned is the difference between non-EU/EEA physicians and EU physicians. EU physicians do not have to go through the same process as non-EU/EEA physicians.

Participating in interventions

Public Employment Service and Public Employment Service office and labour office programme aimed at supporting newly arrived migrants to the labour market was by two-thirds not perceived as having made it easier for them to get a job as a physician in Sweden. The programme had been useful only for a few. A couple of open comments stated that the labour office did not help them, for example: ‘The Public Employment Service’s quick track sounds like a joke but hope this description depends on change since what I experienced in 2013-2014’.

*Courses for physicians educated abroad, to facilitate entrance to route 1 or 2.

Many participated in different courses, but only a few found them useful or valuable.

*Route 2 (CPP)

Some mentioned the CPP in general and some as having saved their career. Participating in the CPP is by some seen as a strategy to increase the possibilities to work as a physician in Sweden, as it is also one of the three routes for obtaining the Swedish licence to practice.

‘The project in itself is very good, that we who do not come from the EU get a place in the Swedish healthcare by updating us how the healthcare system works, and we get to learn the medical terms required to meet a patient’.

However, employers being unfamiliar with the CPP was a perceived reason by 11% of the respondents (n = 283) for having one’s competence undervalued during the job-seeking process.

*Route 1

Being able to switch from route 2 (the CPP) to route 1, since it is perceived to decrease the time for obtaining the Swedish licence to practise. For some, the change of route meant that they did not need to complete the mandatory medical internship.

*Help with CV and job application

An MP commented that ‘the right and interesting personal letter [in job application]’ was a facilitating aspect for work.

To receive help with CV and personal letter was thought as partly, much or very much to be valuable for increasing job opportunities by almost three-quarters of the respondents.

Support

*By others going through the same process

*Being encouraged by mentor