The ongoing globalization of medicine has had a major impact on health care delivery, workforce training and health policies worldwide [1]. The steadily increasing migration of physicians represents a central feature of this process [1,2,3]. In parallel to the growing importance of this migration for the affected societies and health care systems, the phenomenon is receiving increasing attention in both politics and the scientific literature [2]. The magnitude and impact of the globalization of medicine are illustrated through the description of this physician migration as “mass migration” that has created a “critical global health workforce crisis” [4, 5]. The direction of this migration generally occurs along the wealth gap, i.e., from less-developed to more-developed countries and from lower-income to higher-income countries [6,7,8]. The migration of physicians shows some variation in temporal patterns and specific routes in certain regions of the world, e.g., short-term temporary exchange flows versus permanent migration from the Global South to the Global North [9]. Canada, the USA, the UK and Australia represent traditional destination countries with substantial proportions of foreign-trained physicians in their workforces, reaching 23% in the USA, for example [10, 11]. As a result, political economy frameworks that regulate the terms under which foreigners enter the country differ between traditional immigrant receiving countries (e.g., Canada and Australia) and newer countries of immigration (e.g., Germany and Austria), where “legal, administrative, and political mechanisms to control and regulate mass immigration” are still developing [12]. In the following sections, we provide first an overview of the legal and policy frameworks regulating physician mobility at the global, European and German level. This is followed by an illustration of the different theories of integration with a specific emphasis on Esser’s theory of social integration which is used as a framework for this study.

At the global policy level, several international agreements have been put in place to regulate the mobility and recruitment of healthcare workers, e.g., the Global Code of Practice developed by the World Health Organization (WHO), the Health Worker Migration Policy Initiative (HWMPI) and the Global Health Workforce Alliance (GHWA) in 2010 [13]. Following the inception of the European Union, free labour market agreements were issued between its member states, which largely liberated the migration of health care professionals in general and that of physicians in particular [14, 15]. In 1965, the first agreement on intra-European physician mobility was issued, followed by the directive on the free movement of physicians and the recognition of their certificates in 1975. In the same year, the Advisory Committee on Medical Training (ACMT) was established with the responsibility of maintaining high European medical education standards [13].

In Germany, one of the largest member states of the European Union, the uptake of foreign-trained physicians is a relatively new phenomenon, as it is for several other countries in Europe [16]. With regard to the wealth gap and physician migration, Germany is a high-income, industrialized country whose population is constantly ageing [17]. The country has a relatively high density of physicians (1 per 214 inhabitants) [18]. The percentage of migrating physicians increased from 5% in 2006 to 11% in 2016, according to a recent OECD report [19,20,21,22,23,24]. This represents one of the sharpest increases worldwide.

The health care system in Germany is increasingly characterized by a shortage of physicians, especially in rural areas and in the primary care sector [25]. There is a predicted gap of more than 100,000 physicians in 2030, which equates to approx. 25% of all full-time positions today [26]. Germany has slightly increased its medical school capacity in response to the challenge but not in a manner that would address the physician gap predicted for 2030. Thus, the reliance of the German health care system on foreign-trained physicians is likely to intensify substantially in the future. However, there is still a lack of a systematic international institutional recruitment strategy in Germany [27].

Legal frameworks for recognition in Germany regulated by the federal Ministry of Health (Bundesministerium für Gesundheit) have changed over the last decades; welcoming policies were introduced to facilitate the recognition of professional qualifications and the recruitment of migrant physicians [27, 28]. The Recognition Act for foreign qualifications (Anerkennungsgesetz) was introduced in 2012 with the aim of unifying and simplifying the recognition of foreign qualifications and facilitating access to the German labour market for Third Country migrating physicians [29]. Holding German citizenship is no longer a requirement to obtain a licence to practice medicine; instead, Third Country physicians must pass an equivalence medical knowledge examination in addition to German general and medical language exams corresponding to the B2 level and the C1 level of the Common European Framework of Reference for Languages, respectively [30]. EU doctors, in contrast, obtain an automatic full licence, as their qualifications are automatically recognized within Europe [30].

Therefore, the most common source countries of migrating physicians in Germany are other European countries, e.g., Romania and Greece, followed by Middle Eastern countries [21]. The Middle Eastern region covers southwestern Asia and northeastern Africa, extending from Libya in the west to Afghanistan in the east [31]. The region is characterized by constantly changing political environments, low incomes in many countries and substantial emigration of physicians [32]. For countries such as Germany, the integration of physicians from the Middle East can be perceived as a particular challenge, as the linguistic, cultural and religious differences are substantially larger than those faced in the integration of physicians from other European countries.

As migrant physicians play an important role and will play an even more important role in securing healthcare delivery in Germany in the future, there is a need to facilitate their integration into society and the healthcare system. As this integration process represents a multifactorial process between the specific conditions in Germany and the specific characteristics of migrating Middle Eastern physicians, there is a need for empirical research that reveals what challenges they actually face and what hampers their integration process. Based on a better understanding of those integration problems, society, politicians and organizations can take specific measures to facilitate the integration of foreign-trained physicians [26]. Such measures can improve the placement of Middle Eastern physicians in the healthcare workforce, reduce tension, increase retention rates and increase the quality of patient care [5, 33, 34]. At the individual level, benefits may include higher work satisfaction and improved quality of life for immigrating physicians and their families [4, 35]. Increased self-efficacy and cultural health capital as well as reduced feelings of stress and anxiety have an impact on work, interactions and cultural adjustment [36]. In addition, the internationalization of the medical workforce itself can bring enrichment to the needs of multicultural groups within German society.

In the literature and research, there is a debate about the perspective from which the integration processes and experiences of healthcare professionals should be explored best. While some authors prefer the system integration approach that focuses on the integration of the physician workforce on the societal level as a whole, others prefer the social integration approach that examines sociocultural integration on the level of individual actors and their inclusion into the existing social system [18, 37]. From both perspectives, the term “integration” can be defined as “joining parts (in) to an entity,” and its social connotation refers to the “process of mutual accommodation between the majority population and immigrants,” in theory until the point of disappearance of cultural and behavioural differences [38].

To date, much of the literature on the integration of foreign-trained physicians has been written from the system integration perspective, i.e., managing the integration of immigrating physicians into the workforce of a certain health care system at the system level [39]. Several studies have focused on the transition to the workplace, training and job satisfaction of migrating physicians [37]. This perspective emphasizes the so-called “supply side”, for instance, at the level of managing the workforce in a health care system [18, 39]. A prominent example of system integration is the preferential allocation of foreign-trained physicians to rural areas [34].

In contrast, less emphasis has been placed on the social integration processes and experiences of incoming physicians at the individual level, the so-called “demand side” [4, 5, 18, 38], although this perspective seems at least equally important in regard to measuring what facilitates the integration of migrating physicians. In the German context, such research on social integration experience has been undertaken by Klinger and Markmann (2016) on a sample of physicians mainly trained in Romania, Greece and Russia. Given the differences in culture and medical training, their findings may likely be limited in their transferability to physicians trained in Middle Eastern countries [26]. Approaching this topic, a recent study by Los et al. focused on barriers in licence procedures and job application for Syrian-trained physicians following their migration to Germany [25]. While both studies reported in part on social integration experiences, they did not build on an existing integration framework based on theory and empirical studies.

Therefore, this study builds on the theory of social integration by Hartmut Esser, a professor of sociology and philosophy of science at the University of Mannheim, Germany. His work differentiated between system integration, which “refers to the orderly or conflictual relationships between the parts of a social system”, and social integration, which “refers to the orderly or conflictual relationships between the actors” [40]. He developed a theory of social integration that consists of four dimensions of i) acculturation (acquisition of knowledge, language, cultural standards, and competencies); ii) positioning/placement (acquisition and occupation of relevant positions in society and conferral of rights); iii) interaction (establishment of social relations in everyday life, establishment of social networks, cultural capital, and social capital); and iv) identification (emotional attachment to the social system in question via the acquisition of cultural values and orientations) [40]. All four dimensions are interdependent. Placement presupposes a certain acculturation; only with a certain acculturation does placement become possible, and only through this do interaction and identification in a certain social system become possible.

We acknowledge that several other social science theories and frameworks have been developed to explore the integration process of healthcare workers, e.g., Leininger’s theory, including three phases of culture shock, culture stress and cultural imposition, and Pilette’s adjustment theory, including four phases of acquaintance, indignation, conflict resolution and finally integration [37, 41,42,43]. Sociocultural theories of learning and identity development have also been applied to explore the integration experiences of migrating physicians [44]. Hofstede’s cultural dimensions were developed to explain how cultures differ and include power-distance, individualism–collectivism, masculinity–femininity, uncertainty avoidance, and long-term–short-term orientation [45]. Integration into a host country depends on the similarities/differences of cultures; the smaller the cross-cultural transition is, the smoother the integration [45].

The aim of this qualitative study is to explore the individual social integration of Middle Eastern physicians who have migrated to Germany through the lens of the social sciences. We conducted and analysed a series of interviews and focus groups using a deductive approach based on Esser’s four-dimensional model of social integration as a framework. This article represents a companion study to a recent article that explored the driving forces in a group of Middle Eastern physicians from Egypt preparing to migrate to Germany [46].