Locally Trained, Still Foreign: Exploring Belonging and Equity Among Postgraduate International Medical Residents in Türkiye

Locally Trained, Still Foreign: Exploring Belonging and Equity Among Postgraduate International Medical Residents in Türkiye | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Locally Trained, Still Foreign: Exploring Belonging and Equity Among Postgraduate International Medical Residents in Türkiye Adile Berna DURSUN This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8319673/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Objective: This study aims to examine the academic, social, and financial experiences of international medical residents who received their undergraduate training in Türkiye and are currently enrolled in postgraduate clinical training within the country. Methods: In this cross-sectional study, 91 international medical residents working in various universities and training and research hospitals across Türkiye completed an online questionnaire. The survey included demographic data and items related to three domains: academic, social, and financial experiences. Descriptive statistics and comparative analyses were conducted. Results: Participants had a mean age of 30.4 ± 3.7 years; 47% were male, and 73% had received their undergraduate medical education in Turkish. A majority had also completed their medical degrees in Türkiye. Of the respondents, 67% reported advanced Turkish proficiency. The most frequently cited challenge was financial hardship (73.6%); 67% needed a secondary income, and 37% relied on family support. Furthermore, 62.6% reported experiencing differential treatment by patients, peers, or faculty. Academic challenges were significantly associated with language of instruction and type of institution (p < 0.01). Conclusion: Although it is locally trained, the international residents in Türkiye suffer severe financial setbacks and are subject to several types of discrimination in the field of clinical education. The language of instruction and the institutional environment play a far greater role in affecting their academic learning. These findings point to how the supporting mechanisms across the whole system are factors that facilitated the existence of inclusion and equity in Turek's means of medical education in postgraduate studies. International medical residents postgraduate medical education Türkiye equity and inclusion discrimination Introduction Over the past decades, internationalisation of higher education has now viewed as a key aspect of the global academic policy, shifting away, however, to a more comprehensive and inclusive system-wide change (across disciplines) (de Wit et al., 2015 ; Knight, 2003 ). Medical education specifically has seen a growing cross-border student mobility, not only at the undergraduate level but also at the postgraduate clinical level, like resident training. Being one of the top eight countries worldwide for international student enrollment, it is home to over 300,000 international students and has risen to become a regional hub for medical education. A particular aspect of the Turkish context is that a large share of Turkey's international medical residential doctors have done their undergraduate medical education beforehand within the country, usually either in Turkish or English language medical programmes, before creating the move into a national residency training scheme. Unlike the traditional pool of IMGs, who generally spend all their training outside the country of residence and are expatriated only for post-graduate studies (McElvaney and McMahon, 2024 ; Silvestre et al., 2024 ). Although these postgraduate international residents are locally trained, they encounter serious problems in their clinical training and professional assimilation. They are not only issues connected to language or finances, but also perceptions of social marginality, unbalanced treatment, and inadequate organizational support. The global community has brought to the fore the impacts of implicit bias, cultural incompatibility, and unfair studying conditions on the performance and well-being of IMGs (Michalski et al., 2017 ; Covell et al., 2016 ). Nevertheless, little has been studied regarding the specific experience of international residents who are not only trained within the host country but who are considered foreign anyway, namely, in non-English-speaking yet middle-income countries such as Türkiye. Methods Study Design and Participants This study was designed as a cross-sectional, questionnaire-based research targeting international medical residents currently enrolled in postgraduate medical education programs in Türkiye. The study aimed to capture their academic, social, and financial experiences during residency training. Participants were recruited from multiple institutions, including public universities, foundation (non-profit private) universities, private medical faculties, and training and research hospitals. Eligibility criteria included being a foreign national and currently working as a resident physician in Türkiye, regardless of the language or location of their undergraduate medical education. Data Collection Tool Data were collected through an online, structured questionnaire developed specifically for this study. The survey included both demographic items (e.g., age, gender, marital status, years in Türkiye, language proficiency, country of origin, type of institution, specialty area, and medical school background) and structured items grouped into three main domains: Academic experience (e.g., communication with professors and peers, patient interaction, clinical responsibilities, studying) Social experience (e.g., participation in social activities, friendship formation, hobbies, time spent with family) Financial experience (e.g., accommodation, basic expenses, family support, saving/investment, need for additional work) Each item was rated using a 5-point Likert scale ranging from "None" to "Always." Total scores were calculated separately for academic (max: 32), social (max: 32), and financial (max: 19) domains. The questionnaire was developed by academic staff with experience in medical education and postgraduate training. It did not undergo formal pilot testing or psychometric validation due to the exploratory nature of the study; rather, item construction was based on expert consensus and iterative internal review. Data Collection Procedure The survey was distributed via institutional email lists and resident networks. Participation was voluntary, anonymous, and unpaid. Informed consent was obtained digitally at the beginning of the questionnaire. Data Analysis Descriptive statistics (means, standard deviations, frequencies) were used to summarize the participant characteristics and domain scores. Comparative analyses (ANOVA and post hoc tests) were conducted to examine the differences in academic, social, and financial scores across demographic groups, including nationality, language of education, and type of institution. Pearson correlation coefficients were calculated to assess relationships between years spent in Türkiye and domain scores. A significance level of p < .05 was used for all statistical tests. Although the study did not include a formal qualitative component, open-ended comments provided at the end of the questionnaire were reviewed to support and contextualize quantitative findings. These comments were not analyzed using formal qualitative methods such as thematic coding but served as illustrative examples of participant perspectives. Ethical Considerations The study protocol was reviewed and approved by the [Institutional Ethics Committee – to be specified]. Participation was entirely voluntary, and participants had the right to withdraw at any point. All data were kept confidential and analyzed in aggregate. Results Participant Characteristics A total of 91 international medical residents participated in the study. The mean age was 30.45 ± 3.77 years (range: 25–41), with an average duration of residence in Türkiye of 8.58 ± 4.39 years (range: 1–19). Of the participants, 50.5% were female and 47.3% male. More than half (58.2%) were married, and 47.2% had children. In terms of institutional affiliation, participants were distributed across government universities (29.7%), foundation universities (28.6%), private universities (17.6%), and training and research hospitals (24.2%). The majority were enrolled in surgical (46.2%) or non-surgical (31.9%) specialties, while 22% were in basic sciences. Remarkably, 73.4% had completed their undergraduate medical education in Türkiye—either in Turkish (67.0%) or English (26.4%)—indicating that most were integrated into the national medical education system before residency. Nonetheless, only 52.8% identified Turkish as their native language. Turkish language proficiency was reported as advanced in 52.8%, intermediate in 42.9%, and beginner in 4.4%. Overall Problem Burden Participants reported a mean academic difficulty score of 11.44 ± 5.22 (range: 0–22), a social difficulty score of 13.29 ± 6.41 (range: 0–26), and a financial difficulty score of 12.18 ± 3.86 (range: 4–18). The most frequently cited major challenge was financial hardship (73.6%), followed by social (17.6%) and academic (8.8%) issues. Financial Vulnerability A large proportion of participants (67.0%) indicated the need to work additional jobs to support themselves, and 37.4% reported relying on family support. Only 28.6% stated they were able to save or invest. Among financial indicators, accommodation (mean difficulty level: 3.53/5) and family expenses (mean: 3.71/5) were the most burdensome. Foundation university trainees had the highest financial burden (mean: 13.85 ± 3.77), followed by government university trainees (11.33 ± 4.58), though the differences did not reach statistical significance ( p = 0.0714). Academic and Institutional Variation Academic difficulty was significantly associated with institution type ( p = 0.0019). Residents in government universities reported the lowest academic burden (mean score: 8.48 ± 5.03), significantly lower than those in foundation ( p = 0.021), private ( p = 0.035), and training & research hospitals ( p = 0.021). Educational language also impacted academic scores: those trained in Turkish programs had significantly lower academic difficulty (mean: 9.75 ± 4.15) than those educated in English (16.67 ± 3.61, p = 0.007) or other languages ( p = 0.035). Social and Linguistic Disparities While social scores did not differ significantly by nationality, participants whose native language was not Turkish had significantly higher social difficulty scores ( p = 0.0078). Notably, the “other language” group (n = 53) reported the highest mean social score (14.96 ± 6.15). Years lived in Türkiye showed no meaningful correlation with academic or social integration, suggesting persistence of barriers over time. Perception of Discrimination A striking 62.6% of participants reported being treated differently based on their nationality or foreign status. Among these, patients (40.4%), professors (33.3%), and peers (47.4%) were most frequently identified as sources of differential treatment. Discrimination rates varied by nationality: 100% of Western residents and 88.9% of Arabic and Persian residents reported differential treatment, compared to 41.7% of Turkish-citizen residents of foreign origin ( p < 0.001). Institutional differences were also evident: 81.8% of trainees in training and research hospitals reported differential treatment, compared to 40.7% in government universities ( p = 0.024). Representative Comments Although this study primarily employed quantitative methods, a limited number of open-ended responses were collected at the end of the questionnaire. While not systematically analyzed, these comments offer additional insight into the lived experiences of international residents, especially regarding financial hardship and perceived inequities. Several participants reported frustration with unequal compensation and systemic barriers affecting their daily and professional lives. Selected comments include: “We do the same job, but we have lower pay than Turkish residents.” “Payment is too low to live without support.” “Financial problems are the main issue for me.” “There are also problems caused by government regulations regarding residency.” “Despite studying and graduating in Türkiye, I am still treated as an outsider — by both patients and faculty.” “Language is not the main barrier anymore. The problem is how others perceive and treat us.” “There is a sense of being tolerated, not included.” These qualitative reflections are consistent with the quantitative findings and highlight recurring issues in financial, academic, and social domains. They will be further addressed in the discussion section. Discussion A Distinct Cohort in Türkiye’s Medical Education System At the heart of this study are individuals who walk the hospital corridors, care for patients, and share the same workload as their Turkish peers—yet often feel invisible in the system they’ve long been part of. These international residents, trained in Türkiye but still labeled as outsiders, offer a perspective that is both familiar and overlooked. Unlike many international medical graduates (IMGs) who migrate after completing their medical degrees, the majority of international residents in this study completed their undergraduate medical education in Türkiye, either in Turkish or English-language programs. This unique context complicates the conventional understanding of acculturation and adaptation, as these individuals are not newcomers to the academic or clinical system, yet they continue to face distinct challenges in their postgraduate journey. In contrast to the conventional use of “international medical graduate (IMG),” this study deliberately adopts the term postgraduate international residents to reflect the unique positioning of our participants. While the IMG label generally refers to individuals who were educated and trained entirely outside the host country, our participants occupy a hybrid space: they are academically and socially familiar with Türkiye’s medical education system but remain foreign nationals within it. This distinction is crucial, as it influences their integration pathways and highlights nuanced forms of inclusion and exclusion not captured by the global IMG literature. Layers of Discrimination This paper aims to address this gap by investigating the academic, social, and fiscal lives of the postgraduate international residents in Türkiye. By concentrating on perceived challenges as well as the conditions of the place where they are trained, we hope to help build a more nuanced understanding of inclusion and equity in the country's postgraduate medical education system. The theory of situated learning construction of learning, as proposed by Lave and Wenger ( 1991 ), and the notion of institutional belonging guide the study since it acknowledges that clinical learning does not solely occur within classroom instructional programs, but it also occurs through involvement within an educational domain community of practice. Lack of complete acceptance as legitimate members of that community impairs the chances of residents having access to meaningful learning and professional development. Although international residents in TUR have certain similar experiences with the IMGs in other regions of the world, including prejudice, language differences, and structural injustices, their experience is framed by a local context where they are both parties: insiders and outsiders. The structural barriers to entering the IMGs in specific nations, such as the United States and the United Kingdom, have been researched extensively (McElvaney and McMahon, 2024 ; Silvestre et al., 2024 ). Nevertheless, these international postgraduates in Türkiye already have local qualifications and have experience of institutional standards, but they feel ostracised and unjustly treated, especially when it comes to being themselves and their interaction with other staff. The residency entrance system (TUS) of Turkiye offers international applicants their own quota that permits them to enter residency programs with lower scores than Turkish citizens. While this provides access, it also has the potential to make tacit assumptions about competence and merit, which fuel negative attitudes and perceptions during clinical training. To this end, what is perceived to be fairness of opportunity at the entry level can become a paradox once the training starts. Learning environment and Mentorship We found similar results to Chandrashekar and Jain (2020), who argued that the discrimination of clinicians, particularly of minority and foreign-born doctors, stems not only through institutional policies but also through patients and other colleagues. Some international residents in our study indicated that they felt tolerated and not part of the same system, after years of study in the same system. These results are in line with the previous reports on patients who doubted the validity of the residents or their qualities on the grounds of ethnicity, accent, or nationality (Saadi, 2020 ; Wieman, 2020 ). In addition, financial hardship, specifically unequal pay (with reference to Turkish colleagues), was also mentioned by the participants as one of the most serious issues that supports the idea of structural discrimination in the work of the state institutions. Education The learning climate is another issue that, as stated by Silkens et al. ( 2017 ), is of great importance in the training experience of the clinical departments. Some postgraduate international trainees reported that in our study, they were all academically capable and trained locally, yet experienced irregular supervision, scarce feedback, and excluded mentorship. The challenges were not always associated with institutional policies but were identified with the interpersonal behaviour of clinical educators. The explicit or implicit attitudes and assumptions of teaching faculty significantly influence the sense of belonging and professional development of residents. The discovery relates to the gradually accumulating literature worldwide that describes how implicit biases and cultural blindness displayed by teachers can contribute to processes of exclusion, especially in high-stakes settings like residency education (Saadi, 2020 ; Irshad, 2024 ). Moreover, we learn it through the lens of the Situated Learning Theory (Lave and Wenger, 1991 ), which suggests that purposeful learning is taking place in the process of interaction within a community of practice. In cases where postgraduate international residents are not fully recognised as legitimate members of that community, their access to educational and professional development opportunities is limited. Hence, to enhance the living conditions of the international residents in the country, structural changes are not the only way to address the issue, as special faculty training programmes should be developed to facilitate intercultural competence and reflective teaching, not to mention the knowledge of power imbalances in clinical supervision. In this respect, the institutional diversity and inclusion policies and mandatory programmes of faculty development offer a more organised base to designing inclusive clinical learning environments. Such interventions should not only make educators more aware of bias but also provide them with pedagogical instruments for addressing the challenge of supporting a diverse resident body. Strategic Gaps in Postgraduate Support Increased international attractiveness of Turkey as a destination for medical education is reflected in the Internationalization Strategy (2024–2028) of the Turkish Council for Higher Education (YOK). Nevertheless, this strategic outlook has not been entirely translated into postgraduate education. The present paper reveals a contrast between the work of undergraduate inclusivity and postgraduate reality, where support systems at the system level are poorly developed. To take advantage of its investment in international medical education, the retention of well-trained international residents on equitable, inclusive, and structured postgraduate programs is quite necessary in Turkey. Implications and Future Directions The data highlight the need for: Open compensation strategies that remove differences between nationalities. One Up Media Newsletter provides a list of examples of these: "Thirteen ways professors can support underrepresented groups on campus." (2012), "Implicit bias training helps faculty improve classroom climate." "What is implicit bias, and why does it matter?". Policy frameworks recognising the rights and contributions of international residents to the healthcare system through formal policies. Compared to mixed-methods or longitudinal research, further studies that examine professional journeys and the mental health of residents are required. Comparative studies with countries such as Australia (PoPPIL Program; 2025 ), and United States (Cozier, Mellman, & Galea, 2024 ), China (Zhou et al., 2016 ), and Europe could lead to greater insight into the best practices and culturally sensitive policies for postgraduate international medical education. Conclusion This research illuminates the still-unheard experiences of postgraduate international residents in Turkey - individuals who, despite their training within the local medical education system, still encounter systemic inequalities, including unequal remuneration and scant institutional support, and subtle yet persistent exclusion from clinical learning environments. One of the most significant results was that the beliefs and attitudes of the faculty had an influential effect on residents, their sense of belonging, and professional growth. Such interpersonal relations that are not promoted in policy demonstrate the necessity to address faculty development in the given areas (inclusive supervision and intercultural competence) with urgency. Enhancement of the residency experience of this special group cannot be achieved through changes in the policies; it will have to be a cultural change, and this group of international residents is recognised as legitimate and valued stakeholders within the healthcare system of Turkey. The impact and future perspectives, thirdly, of foreign residents through a longitudinal or mixed-methods approach to studying and assessing study design should respond to future perspectives, well-being, and careers of international residents and provide a contribution to culturally responsive and equity-focused reforms in postgraduate medical education. Declarations Ethics approval and consent to participate The study protocol was reviewed and approved by the Memorial Ankara Hospital Clinical Research Ethics Committee. Participation was voluntary and anonymous, and digital informed consent was obtained from all participants before data collection. All procedures involving human participants were conducted in accordance with the ethical standards of the institutional research committee and with the principles of the Declaration of Helsinki. Consent for publication Not applicable; no identifying personal data are included. Availability of data and materials The data that support the findings of this study are available from the corresponding author upon reasonable request. Due to confidentiality and ethical restrictions related to participant privacy, the dataset is not publicly available. Consent for publication Not applicable; no identifying personal data are included in this study. Competing interests The authors declare no competing interests. Funding This research received no external funding. Authors’ contributions Adile Berna DURSUN conceived and designed the study, developed the questionnaire, collected and analyzed the data, and drafted and approved the final manuscript. Acknowledgement There is no acknowledgement section in the document. References Covell CL, Neiterman E, Bourgeault IL. A scoping review of the literature on internationally educated nurses in Canada: Mapping a research agenda. Can J Nurs Res. 2016;48(3–4):9–23. https://doi.org/10.1177/0844562116652230 . 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8319673","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":571663573,"identity":"ba13eec5-ba9d-4f6d-bdff-3cb8dd034170","order_by":0,"name":"Adile Berna DURSUN","email":"data:image/png;base64,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","orcid":"","institution":"Ankara University","correspondingAuthor":true,"prefix":"","firstName":"Adile","middleName":"Berna","lastName":"DURSUN","suffix":""}],"badges":[],"createdAt":"2025-12-09 16:08:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8319673/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8319673/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":100364597,"identity":"d278aa59-107c-4a17-bf07-2c5649578606","added_by":"auto","created_at":"2026-01-16 07:53:59","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":29724,"visible":true,"origin":"","legend":"","description":"","filename":"InternationalResidentsesrahocaya4aug25111.docx","url":"https://assets-eu.researchsquare.com/files/rs-8319673/v1/a1a1b81f608a4d5089a05029.docx"},{"id":100049643,"identity":"1db5f45f-25fb-4cc9-9867-e531fb553fd3","added_by":"auto","created_at":"2026-01-12 12:52:02","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":3940,"visible":true,"origin":"","legend":"","description":"","filename":"32732011e5b344cfb8718ffb21f438b0.json","url":"https://assets-eu.researchsquare.com/files/rs-8319673/v1/f2404c951ee6e0fab528b04b.json"},{"id":100364599,"identity":"951fbe32-51ea-4dd1-a228-4881d0f75d3b","added_by":"auto","created_at":"2026-01-16 07:53:59","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":55573,"visible":true,"origin":"","legend":"","description":"","filename":"32732011e5b344cfb8718ffb21f438b01enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-8319673/v1/db83579e4706e736dd777ba8.xml"},{"id":100364113,"identity":"519d83d2-a2d8-4581-a867-4f0c4cb964ed","added_by":"auto","created_at":"2026-01-16 07:52:37","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":52889,"visible":true,"origin":"","legend":"","description":"","filename":"32732011e5b344cfb8718ffb21f438b01structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8319673/v1/efe6a0860a2b1fc235f51d0b.xml"},{"id":100363437,"identity":"2f65da03-bdec-4795-afcd-264485bcec70","added_by":"auto","created_at":"2026-01-16 07:49:43","extension":"html","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":61558,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8319673/v1/df8190f31e7881ca52df4f1a.html"},{"id":100381568,"identity":"9faffab5-d6e3-46f8-9c4f-470d5e6c34c7","added_by":"auto","created_at":"2026-01-16 10:39:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":749283,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8319673/v1/f88be56a-d73c-483f-b264-5768b35f7595.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Locally Trained, Still Foreign: Exploring Belonging and Equity Among Postgraduate International Medical Residents in Türkiye","fulltext":[{"header":"Introduction","content":"\u003cp\u003eOver the past decades, internationalisation of higher education has now viewed as a key aspect of the global academic policy, shifting away, however, to a more comprehensive and inclusive system-wide change (across disciplines) (de Wit et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Knight, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2003\u003c/span\u003e). Medical education specifically has seen a growing cross-border student mobility, not only at the undergraduate level but also at the postgraduate clinical level, like resident training.\u003c/p\u003e \u003cp\u003e Being one of the top eight countries worldwide for international student enrollment, it is home to over 300,000 international students and has risen to become a regional hub for medical education. A particular aspect of the Turkish context is that a large share of Turkey's international medical residential doctors have done their undergraduate medical education beforehand within the country, usually either in Turkish or English language medical programmes, before creating the move into a national residency training scheme. Unlike the traditional pool of IMGs, who generally spend all their training outside the country of residence and are expatriated only for post-graduate studies (McElvaney and McMahon, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Silvestre et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlthough these postgraduate international residents are locally trained, they encounter serious problems in their clinical training and professional assimilation. They are not only issues connected to language or finances, but also perceptions of social marginality, unbalanced treatment, and inadequate organizational support. The global community has brought to the fore the impacts of implicit bias, cultural incompatibility, and unfair studying conditions on the performance and well-being of IMGs (Michalski et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Covell et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Nevertheless, little has been studied regarding the specific experience of international residents who are not only trained within the host country but who are considered foreign anyway, namely, in non-English-speaking yet middle-income countries such as T\u0026uuml;rkiye.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Participants\u003c/h2\u003e \u003cp\u003eThis study was designed as a cross-sectional, questionnaire-based research targeting international medical residents currently enrolled in postgraduate medical education programs in T\u0026uuml;rkiye. The study aimed to capture their academic, social, and financial experiences during residency training.\u003c/p\u003e \u003cp\u003e Participants were recruited from multiple institutions, including public universities, foundation (non-profit private) universities, private medical faculties, and training and research hospitals. Eligibility criteria included being a foreign national and currently working as a resident physician in T\u0026uuml;rkiye, regardless of the language or location of their undergraduate medical education.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData Collection Tool\u003c/h3\u003e\n\u003cp\u003eData were collected through an online, structured questionnaire developed specifically for this study. The survey included both demographic items (e.g., age, gender, marital status, years in T\u0026uuml;rkiye, language proficiency, country of origin, type of institution, specialty area, and medical school background) and structured items grouped into three main domains:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eAcademic experience (e.g., communication with professors and peers, patient interaction, clinical responsibilities, studying)\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eSocial experience (e.g., participation in social activities, friendship formation, hobbies, time spent with family)\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eFinancial experience (e.g., accommodation, basic expenses, family support, saving/investment, need for additional work)\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eEach item was rated using a 5-point Likert scale ranging from \"None\" to \"Always.\" Total scores were calculated separately for academic (max: 32), social (max: 32), and financial (max: 19) domains. The questionnaire was developed by academic staff with experience in medical education and postgraduate training. It did not undergo formal pilot testing or psychometric validation due to the exploratory nature of the study; rather, item construction was based on expert consensus and iterative internal review.\u003c/p\u003e\n\u003ch3\u003eData Collection Procedure\u003c/h3\u003e\n\u003cp\u003eThe survey was distributed via institutional email lists and resident networks. Participation was voluntary, anonymous, and unpaid. Informed consent was obtained digitally at the beginning of the questionnaire.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eDescriptive statistics (means, standard deviations, frequencies) were used to summarize the participant characteristics and domain scores. Comparative analyses (ANOVA and post hoc tests) were conducted to examine the differences in academic, social, and financial scores across demographic groups, including nationality, language of education, and type of institution. Pearson correlation coefficients were calculated to assess relationships between years spent in T\u0026uuml;rkiye and domain scores. A significance level of p\u0026thinsp;\u0026lt;\u0026thinsp;.05 was used for all statistical tests.\u003c/p\u003e \u003cp\u003eAlthough the study did not include a formal qualitative component, open-ended comments provided at the end of the questionnaire were reviewed to support and contextualize quantitative findings. These comments were not analyzed using formal qualitative methods such as thematic coding but served as illustrative examples of participant perspectives.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthical Considerations\u003c/h3\u003e\n\u003cp\u003e The study protocol was reviewed and approved by the [Institutional Ethics Committee \u0026ndash; to be specified]. Participation was entirely voluntary, and participants had the right to withdraw at any point. All data were kept confidential and analyzed in aggregate.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eParticipant Characteristics\u003c/p\u003e \u003cp\u003eA total of 91 international medical residents participated in the study. The mean age was 30.45\u0026thinsp;\u0026plusmn;\u0026thinsp;3.77 years (range: 25\u0026ndash;41), with an average duration of residence in T\u0026uuml;rkiye of 8.58\u0026thinsp;\u0026plusmn;\u0026thinsp;4.39 years (range: 1\u0026ndash;19). Of the participants, 50.5% were female and 47.3% male. More than half (58.2%) were married, and 47.2% had children.\u003c/p\u003e \u003cp\u003e In terms of institutional affiliation, participants were distributed across government universities (29.7%), foundation universities (28.6%), private universities (17.6%), and training and research hospitals (24.2%). The majority were enrolled in surgical (46.2%) or non-surgical (31.9%) specialties, while 22% were in basic sciences.\u003c/p\u003e \u003cp\u003eRemarkably, 73.4% had completed their undergraduate medical education in T\u0026uuml;rkiye\u0026mdash;either in Turkish (67.0%) or English (26.4%)\u0026mdash;indicating that most were integrated into the national medical education system before residency. Nonetheless, only 52.8% identified Turkish as their native language. Turkish language proficiency was reported as advanced in 52.8%, intermediate in 42.9%, and beginner in 4.4%.\u003c/p\u003e\n\u003ch3\u003eOverall Problem Burden\u003c/h3\u003e\n\u003cp\u003e \u003cb\u003eParticipants reported a\u003c/b\u003e mean academic difficulty score of 11.44\u0026thinsp;\u0026plusmn;\u0026thinsp;5.22 \u003cb\u003e(range: 0\u0026ndash;22), a\u003c/b\u003e social difficulty score of 13.29\u0026thinsp;\u0026plusmn;\u0026thinsp;6.41 \u003cb\u003e(range: 0\u0026ndash;26), and a\u003c/b\u003e financial difficulty score of 12.18\u0026thinsp;\u0026plusmn;\u0026thinsp;3.86 \u003cb\u003e(range: 4\u0026ndash;18). The most frequently cited\u003c/b\u003e major challenge \u003cb\u003ewas\u003c/b\u003e financial hardship \u003cb\u003e(73.6%), followed by social (17.6%) and academic (8.8%) issues.\u003c/b\u003e\u003c/p\u003e\n\u003ch3\u003eFinancial Vulnerability\u003c/h3\u003e\n\u003cp\u003eA large proportion of participants (67.0%) indicated the need to work additional jobs to support themselves, and 37.4% reported relying on family support. Only 28.6% stated they were able to save or invest. Among financial indicators, accommodation (mean difficulty level: 3.53/5) and family expenses (mean: 3.71/5) were the most burdensome. Foundation university trainees had the highest financial burden (mean: 13.85\u0026thinsp;\u0026plusmn;\u0026thinsp;3.77), followed by government university trainees (11.33\u0026thinsp;\u0026plusmn;\u0026thinsp;4.58), though the differences did not reach statistical significance (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0714).\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eAcademic and Institutional Variation\u003c/h2\u003e \u003cp\u003eAcademic difficulty was significantly associated with institution type (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0019). Residents in government universities reported the \u003cb\u003elowest academic burden\u003c/b\u003e (mean score: 8.48\u0026thinsp;\u0026plusmn;\u0026thinsp;5.03), significantly lower than those in foundation (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.021), private (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.035), and training \u0026amp; research hospitals (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.021). Educational language also impacted academic scores: those trained in Turkish programs had significantly lower academic difficulty (mean: 9.75\u0026thinsp;\u0026plusmn;\u0026thinsp;4.15) than those educated in English (16.67\u0026thinsp;\u0026plusmn;\u0026thinsp;3.61, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.007) or other languages (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.035).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eSocial and Linguistic Disparities\u003c/h2\u003e \u003cp\u003eWhile social scores did not differ significantly by nationality, participants whose native language was not Turkish had significantly higher social difficulty scores (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0078). Notably, the \u0026ldquo;other language\u0026rdquo; group (n\u0026thinsp;=\u0026thinsp;53) reported the highest mean social score (14.96\u0026thinsp;\u0026plusmn;\u0026thinsp;6.15). Years lived in T\u0026uuml;rkiye showed no meaningful correlation with academic or social integration, suggesting persistence of barriers over time.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003ePerception of Discrimination\u003c/h2\u003e \u003cp\u003eA striking 62.6% of participants reported being treated differently based on their nationality or foreign status. Among these, patients (40.4%), professors (33.3%), and peers (47.4%) were most frequently identified as sources of differential treatment. Discrimination rates varied by nationality: \u003cb\u003e100% of Western residents\u003c/b\u003e and \u003cb\u003e88.9% of Arabic and Persian residents\u003c/b\u003e reported differential treatment, compared to 41.7% of Turkish-citizen residents of foreign origin (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Institutional differences were also evident: 81.8% of trainees in training and research hospitals reported differential treatment, compared to 40.7% in government universities (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.024).\u003c/p\u003e \u003c/div\u003e\u003ch2\u003eRepresentative Comments\u003c/h2\u003e\n\u003cp\u003eAlthough this study primarily employed quantitative methods, a limited number of open-ended responses were collected at the end of the questionnaire. While not systematically analyzed, these comments offer additional insight into the lived experiences of international residents, especially regarding financial hardship and perceived inequities. Several participants reported frustration with unequal compensation and systemic barriers affecting their daily and professional lives.\u003c/p\u003e\n\u003cp\u003eSelected comments include:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We do the same job, but we have lower pay than Turkish residents.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Payment is too low to live without support.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Financial problems are the main issue for me.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;There are also problems caused by government regulations regarding residency.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Despite studying and graduating in T\u0026uuml;rkiye, I am still treated as an outsider \u0026mdash; by both patients and faculty.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Language is not the main barrier anymore. The problem is how others perceive and treat us.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;There is a sense of being tolerated, not included.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThese qualitative reflections are consistent with the quantitative findings and highlight recurring issues in financial, academic, and social domains. They will be further addressed in the discussion section.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eA Distinct Cohort in T\u0026uuml;rkiye\u0026rsquo;s Medical Education System\u003c/h2\u003e \u003cp\u003eAt the heart of this study are individuals who walk the hospital corridors, care for patients, and share the same workload as their Turkish peers\u0026mdash;yet often feel invisible in the system they\u0026rsquo;ve long been part of. These international residents, trained in T\u0026uuml;rkiye but still labeled as outsiders, offer a perspective that is both familiar and overlooked. Unlike many international medical graduates (IMGs) who migrate after completing their medical degrees, the majority of international residents in this study completed their undergraduate medical education in T\u0026uuml;rkiye, either in Turkish or English-language programs. This unique context complicates the conventional understanding of acculturation and adaptation, as these individuals are not newcomers to the academic or clinical system, yet they continue to face distinct challenges in their postgraduate journey.\u003c/p\u003e \u003cp\u003eIn contrast to the conventional use of \u0026ldquo;international medical graduate (IMG),\u0026rdquo; this study deliberately adopts the term \u003cem\u003epostgraduate international residents\u003c/em\u003e to reflect the unique positioning of our participants. While the IMG label generally refers to individuals who were educated and trained entirely outside the host country, our participants occupy a hybrid space: they are academically and socially familiar with T\u0026uuml;rkiye\u0026rsquo;s medical education system but remain foreign nationals within it. This distinction is crucial, as it influences their integration pathways and highlights nuanced forms of inclusion and exclusion not captured by the global IMG literature.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eLayers of Discrimination\u003c/h2\u003e \u003cp\u003eThis paper aims to address this gap by investigating the academic, social, and fiscal lives of the postgraduate international residents in T\u0026uuml;rkiye. By concentrating on perceived challenges as well as the conditions of the place where they are trained, we hope to help build a more nuanced understanding of inclusion and equity in the country's postgraduate medical education system. The theory of situated learning construction of learning, as proposed by Lave and Wenger (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e1991\u003c/span\u003e), and the notion of institutional belonging guide the study since it acknowledges that clinical learning does not solely occur within classroom instructional programs, but it also occurs through involvement within an educational domain community of practice. Lack of complete acceptance as legitimate members of that community impairs the chances of residents having access to meaningful learning and professional development.\u003c/p\u003e \u003cp\u003eAlthough international residents in TUR have certain similar experiences with the IMGs in other regions of the world, including prejudice, language differences, and structural injustices, their experience is framed by a local context where they are both parties: insiders and outsiders. The structural barriers to entering the IMGs in specific nations, such as the United States and the United Kingdom, have been researched extensively (McElvaney and McMahon, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Silvestre et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Nevertheless, these international postgraduates in T\u0026uuml;rkiye already have local qualifications and have experience of institutional standards, but they feel ostracised and unjustly treated, especially when it comes to being themselves and their interaction with other staff.\u003c/p\u003e \u003cp\u003eThe residency entrance system (TUS) of Turkiye offers international applicants their own quota that permits them to enter residency programs with lower scores than Turkish citizens. While this provides access, it also has the potential to make tacit assumptions about competence and merit, which fuel negative attitudes and perceptions during clinical training. To this end, what is perceived to be fairness of opportunity at the entry level can become a paradox once the training starts.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eLearning environment and Mentorship\u003c/h2\u003e \u003cp\u003eWe found similar results to Chandrashekar and Jain (2020), who argued that the discrimination of clinicians, particularly of minority and foreign-born doctors, stems not only through institutional policies but also through patients and other colleagues. Some international residents in our study indicated that they felt tolerated and not part of the same system, after years of study in the same system. These results are in line with the previous reports on patients who doubted the validity of the residents or their qualities on the grounds of ethnicity, accent, or nationality (Saadi, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Wieman, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). In addition, financial hardship, specifically unequal pay (with reference to Turkish colleagues), was also mentioned by the participants as one of the most serious issues that supports the idea of structural discrimination in the work of the state institutions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eEducation\u003c/h2\u003e \u003cp\u003eThe learning climate is another issue that, as stated by Silkens et al. (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2017\u003c/span\u003e), is of great importance in the training experience of the clinical departments. Some postgraduate international trainees reported that in our study, they were all academically capable and trained locally, yet experienced irregular supervision, scarce feedback, and excluded mentorship. The challenges were not always associated with institutional policies but were identified with the interpersonal behaviour of clinical educators. The explicit or implicit attitudes and assumptions of teaching faculty significantly influence the sense of belonging and professional development of residents.\u003c/p\u003e \u003cp\u003eThe discovery relates to the gradually accumulating literature worldwide that describes how implicit biases and cultural blindness displayed by teachers can contribute to processes of exclusion, especially in high-stakes settings like residency education (Saadi, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Irshad, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Moreover, we learn it through the lens of the Situated Learning Theory (Lave and Wenger, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e1991\u003c/span\u003e), which suggests that purposeful learning is taking place in the process of interaction within a community of practice. In cases where postgraduate international residents are not fully recognised as legitimate members of that community, their access to educational and professional development opportunities is limited. Hence, to enhance the living conditions of the international residents in the country, structural changes are not the only way to address the issue, as special faculty training programmes should be developed to facilitate intercultural competence and reflective teaching, not to mention the knowledge of power imbalances in clinical supervision.\u003c/p\u003e \u003cp\u003eIn this respect, the institutional diversity and inclusion policies and mandatory programmes of faculty development offer a more organised base to designing inclusive clinical learning environments. Such interventions should not only make educators more aware of bias but also provide them with pedagogical instruments for addressing the challenge of supporting a diverse resident body.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eStrategic Gaps in Postgraduate Support\u003c/h2\u003e \u003cp\u003eIncreased international attractiveness of Turkey as a destination for medical education is reflected in the Internationalization Strategy (2024\u0026ndash;2028) of the Turkish Council for Higher Education (YOK). Nevertheless, this strategic outlook has not been entirely translated into postgraduate education. The present paper reveals a contrast between the work of undergraduate inclusivity and postgraduate reality, where support systems at the system level are poorly developed. To take advantage of its investment in international medical education, the retention of well-trained international residents on equitable, inclusive, and structured postgraduate programs is quite necessary in Turkey.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eImplications and Future Directions\u003c/h2\u003e \u003cp\u003eThe data highlight the need for:\u003c/p\u003e \u003cp\u003eOpen compensation strategies that remove differences between nationalities.\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eOne Up Media Newsletter provides a list of examples of these: \"Thirteen ways professors can support underrepresented groups on campus.\" (2012), \"Implicit bias training helps faculty improve classroom climate.\" \"What is implicit bias, and why does it matter?\".\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePolicy frameworks recognising the rights and contributions of international residents to the healthcare system through formal policies.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eCompared to mixed-methods or longitudinal research, further studies that examine professional journeys and the mental health of residents are required.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eComparative studies with countries such as Australia (PoPPIL Program; \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2025\u003c/span\u003e), and United States (Cozier, Mellman, \u0026amp; Galea, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), China (Zhou et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2016\u003c/span\u003e), and Europe could lead to greater insight into the best practices and culturally sensitive policies for postgraduate international medical education.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis research illuminates the still-unheard experiences of postgraduate international residents in Turkey - individuals who, despite their training within the local medical education system, still encounter systemic inequalities, including unequal remuneration and scant institutional support, and subtle yet persistent exclusion from clinical learning environments.\u003c/p\u003e \u003cp\u003eOne of the most significant results was that the beliefs and attitudes of the faculty had an influential effect on residents, their sense of belonging, and professional growth. Such interpersonal relations that are not promoted in policy demonstrate the necessity to address faculty development in the given areas (inclusive supervision and intercultural competence) with urgency.\u003c/p\u003e \u003cp\u003eEnhancement of the residency experience of this special group cannot be achieved through changes in the policies; it will have to be a cultural change, and this group of international residents is recognised as legitimate and valued stakeholders within the healthcare system of Turkey.\u003c/p\u003e \u003cp\u003eThe impact and future perspectives, thirdly, of foreign residents through a longitudinal or mixed-methods approach to studying and assessing study design should respond to future perspectives, well-being, and careers of international residents and provide a contribution to culturally responsive and equity-focused reforms in postgraduate medical education.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was reviewed and approved by the Memorial Ankara Hospital Clinical Research Ethics Committee. Participation was voluntary and anonymous, and digital informed consent was obtained from all participants before data collection. All procedures involving human participants were conducted in accordance with the ethical standards of the institutional research committee and with the principles of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable; no identifying personal data are included.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the corresponding author upon reasonable request. Due to confidentiality and ethical restrictions related to participant privacy, the dataset is not publicly available.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable; no identifying personal data are included in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAdile Berna DURSUN conceived and designed the study, developed the questionnaire, collected and analyzed the data, and drafted and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere is \u003cstrong\u003eno acknowledgement section\u003c/strong\u003e in the document.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCovell CL, Neiterman E, Bourgeault IL. 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Chin Med J. 2016;129(11):1321\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.4103/0366-6999.182833\u003c/span\u003e\u003cspan address=\"10.4103/0366-6999.182833\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"International medical residents, postgraduate medical education, Türkiye, equity and inclusion, discrimination","lastPublishedDoi":"10.21203/rs.3.rs-8319673/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8319673/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective:\u003c/h2\u003e \u003cp\u003eThis study aims to examine the academic, social, and financial experiences of international medical residents who received their undergraduate training in T\u0026uuml;rkiye and are currently enrolled in postgraduate clinical training within the country.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eIn this cross-sectional study, 91 international medical residents working in various universities and training and research hospitals across T\u0026uuml;rkiye completed an online questionnaire. The survey included demographic data and items related to three domains: academic, social, and financial experiences. Descriptive statistics and comparative analyses were conducted.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eParticipants had a mean age of 30.4\u0026thinsp;\u0026plusmn;\u0026thinsp;3.7 years; 47% were male, and 73% had received their undergraduate medical education in Turkish. A majority had also completed their medical degrees in T\u0026uuml;rkiye. Of the respondents, 67% reported advanced Turkish proficiency. The most frequently cited challenge was financial hardship (73.6%); 67% needed a secondary income, and 37% relied on family support. Furthermore, 62.6% reported experiencing differential treatment by patients, peers, or faculty. Academic challenges were significantly associated with language of instruction and type of institution (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e \u003cp\u003eAlthough it is locally trained, the international residents in T\u0026uuml;rkiye suffer severe financial setbacks and are subject to several types of discrimination in the field of clinical education. The language of instruction and the institutional environment play a far greater role in affecting their academic learning. These findings point to how the supporting mechanisms across the whole system are factors that facilitated the existence of inclusion and equity in Turek's means of medical education in postgraduate studies.\u003c/p\u003e","manuscriptTitle":"Locally Trained, Still Foreign: Exploring Belonging and Equity Among Postgraduate International Medical Residents in Türkiye","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-12 12:51:57","doi":"10.21203/rs.3.rs-8319673/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-01-20T13:05:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"228765456401157577748335154359042819761","date":"2026-01-20T06:31:14+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-08T07:09:24+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-05T09:24:34+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-17T12:32:42+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-17T10:28:56+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-12-17T10:21:30+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"18bee850-0f52-4b89-89ae-d8919e1c2b91","owner":[],"postedDate":"January 12th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-12T12:51:57+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-12 12:51:57","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8319673","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8319673","identity":"rs-8319673","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}