Refugee doctors experience difficulties in finding regular medical work in their host countries.1 Although they can be conceptually classified as international medical graduates (IMGs), the conditions of these doctors are significantly worse than those of typical IMGs.2 Often, they leave their home country under conditions of extreme confidentiality, haste, or stress and may be unable to bring proof of their medical qualifications or graduate degrees to their new countries. In general, refugee doctors encounter considerable difficulties with the host country's language and may experience difficult emotional and financial conditions. Consequently, they are less likely to be accepted as medical doctors in their host country.
The specific circumstances of refugee doctors are difficult to generalize because of their unique contexts since such doctors experience various localized difficulties and obstacles in acquiring a doctoral license in host countries. Compounding these challenges is the host country's level of acceptance of refugee doctors politically, culturally, and in practice. Therefore, policy support for refugee doctors should address the various context-specific situations in which individuals find themselves. In countries such as the United Kingdom and Canada, where medical services are publicly funded, various support programs have been implemented for refugee doctors to reduce their barriers to practicing medicine.3,4 However, little is known about the situations of refugee doctors outside these two countries; it is difficult to ascertain the existence or operation of any support programs for them in other countries.
North Korean refugee doctors (NKRDs) are a unique type of refugee doctors who have migrated to South Korea because of the political persecution, food shortages, and professional limitations prevalent in North Korea. Many NKRDs who are currently settled in South Korea have attempted to acquire a license to practice medicine.5 However, since the South Korean constitution does not officially recognize North Korea as a legitimate state, NKRDs are not considered IMGs in South Korea.6 Consequently, the South Korean government recognizes NKRDs as having an educational level equivalent to graduation from a South Korean medical school and allows them to apply for the medical licensing examination only after they pass a credential approval process.7 The Credential Committee for International Graduates of the Korea Health Personnel Licensing Examination Institute (KHPLEI) reviews each application and manually confirms each applicant's diploma brought from North Korea. Furthermore, the Committee may require the applicant to provide supplementary documents and appear in person to answer questions and provide the necessary information. If an applicant fails to submit the necessary documents or does not appear before the Committee within 20 days of being notified, the Committee may terminate his or her evaluation.7 As of 2016, 87 NKRDs had applied for the medical licensing examination, among whom 47 proceeded to the eligibility screening stage; of these, 24 passed the examination and acquired their South Korean medical license.8
It is noted that opinions on the obstacles to becoming a South Korean doctor (SKD) are mixed. Although some SKDs stated that this barrier should be lowered for NKRDs, others opined that further compromise is unacceptable. However, such a discussion requires a comprehensive and in-depth examination of the NKRDs' experiences and opinions on preparing for medical license acquisition in South Korea and performing all subsequent processes. Moreover, the perspectives of SKDs on these topics should be examined.
Accordingly, this study examines the experiences and opinions of NKRDs who have attempted to acquire a medical license in South Korea, as well as the opinions of South Korean experts, or SKDs, who have directly or indirectly participated in the aforementioned process. In addition, the study identifies and analyzes the implications and discussion points pertaining to these experiences and opinions.
MATERIALS AND METHODS
This study drew upon two phenomenological methodologies, the Colaizzi method and van Manen method9–11 to interpret the real-life experiences of NKRDs who have attempted to acquire a medical license in South Korea.
The 23 participants of this study were divided into 2 groups. The first group comprised 16 NKRDs recruited through snowball sampling,12 whereas the second group contained seven SKDs who were experienced in conducting programs assisting NKRDs in the latter's efforts to secure a license to practice medicine in South Korea (Table 1).
Data were collected through face-to-face in-depth interviews. The participants were interviewed between February and September 2015 at various places, including coffee shops and the participants' homes. Each interview took approximately an hour. A voice recorder and a laptop computer were used to collect data and take notes. Interviews were conducted by one of the authors of this study (H.R.C.), a former NKRD who had acquired a medical license in South Korea, and who ensured thoroughness in questioning based on personal experience. Before the interview, she telephoned the participants to explain the purpose and content of the study. The researchers developed their own questions because no questions were available on topics pertaining to NKRDs. Subsequently, all the authors reviewed these questions. Although there were slight differences in the composition of the questions given to NKRDs and SKDs, those questions were developed and applied to examine the experiences and opinions of the two parties regarding medical license acquisition in South Korea. In addition, other modes of contact, including social networking sites, were used to supplement insufficient information, where required.
The recorded data were subjected to concept listing through the following processes: transcription, understanding the transcribed data, categorization of contents, and discussion. While listening to the recordings, the researchers transcribed the recorded interviews and repeated this process to enhance the thoroughness and accuracy of the copied notes.
Analysis was performed based on the written transcripts using the Colaizzi process for descriptive phenomenological data analysis.13 First, we read the transcripts repeatedly and carefully to get a general sense of the entire content. We then derived significant statements from phrases and sentences. Meanings were formulated from these significant statements whereby we then organized the derived formulated meanings into themes, theme clusters, categories, and categorized domains. An exhaustive description with a clear statement in relation to the phenomenon of interest was generated. Finally, we described the fundamental structure of the phenomenon; specifically, words, phrases, and sentences that were particularly noticeable within participants' statements were identified and analyzed to derive the process, structure, and meaning of their experiences.
This study was approved by the institutional review board of the Institute for Health and Unification Studies, Seoul National University College of Medicine (C-1502-072-649). Before each interview, the interviewer explained the objective and relevance of the study and obtained informed written consent from each participant on how the information collected from them would be used.
The problems and opinions associated with the processes before and after the acquisition of a South Korean medical license by an NKRD were classified into five domains, namely educational approval, career approval, cultural differences, economic problems, and retraining and career development. As shown in Table 2, thematic analysis identified 10 and 8 themes corresponding to NKRDs and SKDs, respectively.
Domain 1: Educational Approval
Recognition of their educational credentials is a prerequisite for NKRDs to acquire a South Korean medical license. Only those NKRDs who pass the interview conducted by the KHPLEI can have their credentials recognized and become eligible to attend the medical license examination. Furthermore, similarities and differences existed in the opinions of NKRDs and SKDs regarding the process of recognizing the former's educational credentials.
Necessity of Adjusting the Assessment of Educational Credentials
NKRDs stated that the oral interview should be eliminated to improve the process of educational credential assessment. Conversely, some SKDs recognized the necessity of implementing a more stringent credential recognition process.
“As long as North Korean medical school credentials are recognized, it would be better if the eligibility to take the national medical license examination was provided without the oral interview process …” (#N8).
“… I believe that the assessment system is still insufficient. Based on my experience, I believe a more extensive and detailed assessment system is needed …” (#S1).
(Dis)trust of the KHPLEI
NKRDs questioned the fairness of the KHPLEI; some even doubted the transparency and objectivity of its interview process. Unlike NKRDs, SKDs trusted in the fairness of the educational credential recognition process conducted by the KHPLEI. Moreover, some of the SKDs discounted concerns raised by NKRDs, such as the lack of process objectivity and fairness by the KHPLEI.
Domain 2: Recognition of Previous Clinical Experience
With respect to the specialist training in which NKRDs can participate after acquiring their South Korean medical license, NKRDs and SKDs had the same opinion regarding the necessity of establishing and expanding a system through which NKRDs can acquire a South Korean medical license and of recognition by the South Korean government of the clinical experience obtained by NKRDs in North Korea.
NKRDs opined that the entire process of career validation should be completed through testing or a shorter training period. They did not consider the training processes in North Korea and South Korea to be significantly different and felt that they had already received adequate training in North Korea. NKRDs believed that gaining recognition for their clinical experience in North Korea should be possible through one-time testing. Regarding their clinical experience, they stated that it is unnecessary for them to attend the specialist training in South Korea.
“… in view of the experience or connection to North Korea, I agree that exams should be taken during the residency period, but does it have to be [for] four full years? I specialized in gastroenterology work for 15 years, but I'm doing gastroenterology residency now …” (#N3).
Domain 3: Cultural Differences
With respect to the medical educational environments in South Korea and North Korea, both NKRDs and SKDs recognized the differences in medical culture, including the use of English for medical terms in the South Korean medical educational environment. Such language use presents difficulties for NKRDs in acquiring a South Korean medical license and in providing medical services in a clinical setting. Since English is the dominant language used in the South Korean medical educational environment, NKRDs felt alienated; they perceived this language barrier as the largest problem to be addressed in the medical license acquisition process. In addition, SKDs recognized that NKRDs would face difficulties in license acquisition because of the differences in the medical educational environments of South Korea and North Korea; however, they did not perceive such difficulties as major barriers to license acquisition.
“They use English as the educational language in South Korea while North Korea uses Korean almost exclusively” (#N8).
“…I believe [that] the assessment [for the medical license acquisition] is still insufficient. Based on my experience, I believe [that a] more extensive and detailed assessment is actually needed…” (#S1).
NKRDs perceived differences in the educational environment, specifically in the type of testing and the level of diagnostic equipment used in hospitals. SKDs shared the same perception regarding these areas and noted the difference in the duration of the clinical practicum between the two countries.
“In my opinion, there is a significant difference in curriculum between North Korea and South Korea…” (#N4).
“…since I've been living here, I [have] noticed that methods of treatment mostly differ between North Korea and South Korea…” (#N11).
Feeling of Discomfort in the Field
NKRDs believed that South Korean experts, including SKDs, do not completely adhere to the regulations implemented in South Korea regarding the institutional support provided to NKRDs. They further believed that NKRDs were considered to be defectors and were being discriminated against. Conversely, SKDs considered the efforts of South Korean experts, including themselves, to help NKRDs acquire a medical license and gain employment in the medical field, to be motivated by compassion and not based on institutional regulations.
“… it's difficult to claim that there was discrimination in the screening process because of being a defector from North Korea. That's because it is a screening process” (#S4).
Domain 4: Economic Problems
It is noted that although NKRDs complained of financial difficulties, SKDs pointed out the challenges encountered in securing a budget for projects and services related to NKRDs, including license acquisition.
Personal Economic Problems
NKRDs stated that they were aware of the financial difficulties that must be resolved to support their personal lives during the license acquisition process. However, it is noted that some NKRDs had given up on acquiring a medical license and accepted non–health care jobs to resolve their financial difficulties.
“I had financial difficulties since I had to leave my two daughters at home and go all the way to Hwacheon [in] Gangwon Province to study [for the medical license acquisition]…” (#N8).
SKDs maintained that the government must secure an appropriate system and budget for NKRDs to enable the latter to acquire a South Korean medical license. Moreover, SKDs perceived that providing support for NKRDs in medical license acquisition alone, as has been the case to date, may raise concerns about equal treatment toward other North Korean defectors with respect to facilitating their settlement in South Korea.
Domain 5: Retraining and Career Development
Some NKRDs stated that they should receive education before and specialist training after license acquisition. Furthermore, SKDs emphasized the necessity of education before license acquisition, in addition to customized specialist programs, which should be preceded by an objective assessment of the NKRDs' medical competency levels, including their educational experience. Moreover, they indicated the importance of establishing a government-led specialist development program and system.
“It's absolutely necessary. I agree wholeheartedly with that part, i.e., if those kinds of educational courses are available, they should be applied right away…” (#N3).
“The government or Ministry of Health and Welfare needs to come up with a plan” (#S5).
Education for License Acquisition
NKRDs requested educational courses for medical license acquisition. By contrast, SKDs maintained that although the medical education in North Korea satisfied the basic standards of South Korean medical education, it is necessary to update and supplement the former.
“…if I were to say which courses are especially needed, they [should] do everything that's available over there [in North Korea] and, I think, perhaps the content needs to be more up to date. I also think that practical training should be added on top of that” (#S3).
Necessity of Education After License Acquisition
Both NKRDs and SKDs indicated that although the training process after license acquisition is a common concern for all doctors, the selection of the training institution and participation is based on personal choice.
“License acquisition should be assessed [based on] the same qualifications as for South Korean students, just as it is now. But, the process of becoming a specialist, i.e., internship, is meaningless to [those of] us who have extensive clinical experience. The residency [program] should be changed to allow us to take the exam after just one year of residency, to widen the road to developing North Korean specialists under a unified Korea” (#N8).
“After acquiring the license, training for that itself is a personal choice. But, something like that could be done by identifying what is appropriate for one's self…”(#S3).
“In terms of training, it's in fact the same for friends here, in the South, who have acquired their license. There are definitely people who don't adjust well and leave, and there are many training opportunities after acquiring the license” (#S3).
Professional Customized Retraining
SKDs maintained that retraining should be provided by experts and implemented in a professional and organized manner.
“…a person who plans how customized training can be implemented for each individual… Therefore, a coordinator who decides which direction training should take, is needed…” (#S3).
During the early stages of their settlement in South Korea, most of the NKRDs expressed a strong willingness to work as doctors based on the specialty, experience, and credentials that they had acquired in North Korea. This is reaffirmed by their determination to advance themselves professionally, a phenomenon that is stronger among doctors than among people of any other profession who have moved from North Korea to South Korea.14 Although NKRDs were proud of their contributions as doctors in the North Korean society, few of them could obtain South Korean medical licenses because of the barriers analyzed in this study.5,15 The major thematic findings are as follows:
NKRDs shared the common perception that they faced difficulties at every stage of acquiring a South Korean medical license, particularly in having their educational credentials recognized. They believe that NKRDs are expected to meet excessively high professional standards compared with SKDs, and hence, such standards must be relaxed for the former. By contrast, although SKDs agreed on the need to improve the license acquisition process, they suggested a significantly different direction, such as one involving a testing process with even higher standards. Although NKRDs perceived the eligibility certification process to be necessary for promoting economic stability in South Korea and reconfirming their qualifications from North Korea to gain eligibility and social status, SKDs perceived it as a stringent and objective recertification process that was necessary for doctors practicing medicine.
Both NKRDs and SKDs acknowledged the need for recognizing the clinical experience of NKRDs in North Korea. NKRDs complained that their experience was not completely recognized in South Korea, whereas SKDs were concerned with establishing procedures, systems, and fair and objective standards for recognizing the clinical experience of NKRDs. However, SKDs did not want South Korean standards to be relaxed on the premise that the medical knowledge of NKRDs is below the standards implemented for medical license acquisition and specialist training in South Korea. Moreover, both NKRDs and SKDs understood that cultural differences between the medical education systems in North Korea and South Korea affected medical license acquisition standards implemented in the respective countries.16 NKRDs asserted that changes in the South Korean standards for medical license acquisition are required because the practical and written assessments conducted by the KHPLEI considered neither the cultural differences in medical training between the North and South Koreas nor the socioeconomic challenges faced by NKRDs in their efforts to acquire a South Korean medical license.
SKDs expressed the need to establish, expand, and support the license acquisition system for NKRDs based on their past experience.17 It was noted that the competency of NKRDs should be strengthened to meet South Korean standards; however, this improvement in competency can be realized only through extensive discussions and preparation in terms of policy making and implementation. For instance, some SKDs proposed that NKRDs having more than 10 years of clinical experience in North Korea should be given a temporary license without having to attend the national examination; in addition, NKRDs could be granted a permanent license after 1 year of clinical training.6 This compassionate approach toward recognizing the medical specialty of NKRDs was proposed, although the content and culture of medical training in North Korea differ from those in South Korea,18 as shown in this study.
From an international perspective, although West Germany unconditionally accepted the licenses of East German doctors during German reunification, the medical education and training implemented in West Germany and East Germany did not differ much from international standards.19 In Israel, doctors from the Soviet Union who had practiced medicine for at least 20 years received their medical license after 6 months of training, whereas those with less than 20 years of practical experience were tested.20,21 These cases show that licenses can be granted only if the medical quality of both the home and asylum countries of refugee doctors can be guaranteed to a certain extent.22
Currently, South Korea has the lowest number of doctors per capita among members of the Organization for Economic Co-operation and Development.23 However, it is difficult to predict that SKDs' community will be able to comfortably accommodate NKRDs because this community does not seem to welcome an increase in the number of doctors due to various reasons.24 Therefore, it is necessary to implement a rigorous and valid evaluation method that can prove and improve the medical potential of NKRDs. A study in which NKRDs were assessed for their medical knowledge has shown that doctors had a significant increase in score in their second test.25 Hence, it has been shown that NKRDs can adapt to the standard level if they are given sufficient time to adapt themselves to unfamiliar medical knowledge. If such obstacles are reduced and sufficient support is provided to them, then NKRDs may become more competitive.
Refugee doctors such as NKRDs require more specific support than typical IMGs. In addition to the difficulties faced by IMGs in host countries, refugee doctors encounter difficulties such as those pertaining to residence, language, emotions, finances, and career and academic credentials. Such difficulties pose major obstacles to their potential competitiveness, and their expertise may become devalued and, eventually, obsolete.
The medical licensing processes of developed countries, which assess the knowledge of highly advanced diagnostic and therapeutic skills, are unfamiliar to refugee doctors; hence, they are likely to be evaluated as being at an inferior level. Refugee doctors, who had acquired clinical experiences in unfavorable medical environments in their homeland, argued that they have a clinical competitive edge over doctors in developed countries, who rely more on machines and technology than experience.26 Some experts argue that physicians trained in foreign countries cannot rely on all the technological measures that are available to doctors in developed countries; hence, they can outperform their host country colleagues in practice.26 A study showed that patients in the United States treated by foreign-trained doctors were less likely to die within 30 days of hospital admission.27 Therefore, measures should be developed further to assess refugee doctors' experience and abilities, which will enable them to apply their experience and skills in using current, standardized medical technology. Further research is also necessary to determine the extent to which refugee doctors' potential capabilities are revealed as a result of providing such support.28 Moreover, as mentioned in the introduction of this article, determining the greatest obstacle to improving their abilities is crucial, since refugee doctors are in various social circumstances.
Furthermore, SKDs opined that the provision of special governmental support to NKRDs could cause equity problems with other professions. The main reason for this concern is that the training of doctors in South Korea is provided by the private sector. The optional support provided by the state to the private sector in this regard may be considered an unfair advantage. Nonetheless, it is desirable to support them with the government initiative. It is necessary to refer to the training program for foreign doctors of developed countries.
The limitations of this study are related to the inherent limitation of snowball sampling. Some of the study results may not be empirically generalizable; nonetheless, the strength of the study is in its conceptual generalizability about the key themes outlined: educational approval, career approval, cultural differences, economic problems, and retraining and career development.
NKRDs encounter great difficulty in acquiring a medical license in South Korea because of differences between their home and host countries in terms of culture and the use of medical terminology, as well as the uncertainty in license approval and the evaluation process in South Korea. Although SKDs could identify some problems with the evaluation process, they raised a fundamental question on the medical competency of NKRDs. However, both the groups shared the common opinion that the aforementioned obstacles should be eliminated to support NKRDs in their efforts to improve and demonstrate their skills.
Lessons for Practice
- [Black Square] Many North Korean refugee doctors who have defected to South Korea face difficulties at every stage of medical license acquisition, particularly with respect to the recognition of their educational credentials.
- [Black Square] Practical and written assessments conducted by the South Korean medical authority should be sensitive to cultural differences in medical training between North Korea and South Korea.
- [Black Square] The strengthening of North Korean doctors' competencies to meet South Korean standards should be supported.
- [Black Square] A support system must be established for refugee doctors.