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FEATURE: Edward Byrne Should postgraduate training places be reserved for UK graduates? Yes BMJ 2007; 335: 590 [Full text]

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Medical training in the UK.

Marianthi Gkreka   (21 September 2007)

Introspection

Debashis Bhattacharya   (21 September 2007)

Right for training positions

gopalakrishna s chinnari   (22 September 2007)

Not as simple as it appears

Vivek A Furtado   (22 September 2007)

Scapegoats

Jayaprakash Ayillath Gosalakkal   (22 September 2007)

Training of UK graduates must not be wasted

John Bache   (24 September 2007)

Do Surgical Fellowship Programmes in the UK have a quality control?

Chelliah R Selvasekar   (24 September 2007)

Workforce planning a wicked problem

E Hassen   (24 September 2007)

Three reasons to give priority to UK graduates

Usama Alkhaddour   (24 September 2007)

Manpower

Jayaprakash Ayillath Gosalakkal   (25 September 2007)

Tricky One

Tim E C Bushell   (27 September 2007)

Practice exchanges

Stephen Cohen   (28 September 2007)

Sham!

Sunil Kumar   (20 October 2007)

It should be fair

Sandhya Gaur   (21 October 2007)

Very Disappointed

M S AFZAL   (21 October 2007)

Medical training in the UK. 21 September 2007
Marianthi Gkreka, SHO Bournemouth Send response to journal: Re: Medical training in the UK.	I read Edward Byrne's article with interest. Particularly interesting I found his statement that "It is appropriate that a country with the wealth and stature of the United Kingdom cover its medical workforce needs without drawing doctors from less well advantaged countries in Europe or elsewhere". My personal experience, having worked in the NHS for the last 2 years, is that many UK trained colleagues are excellent doctors. Some others' knowledge and skills are not so good. The situation is the same in Greece and, I believe, in Germany, India, Pakistan, South Africa and anywhere else in the world. "Advantaged" and "disadvantaged" countries can produce both excellent and less good doctors. Moreover, I would not underestimate the fact that doctors who practise Medicine in a language other than their mother tongue, have proven a high level of commitment and skill. On the other hand I can understand the frustration caused by MTAS and the need to blame someone.Resisting this attitude would help maintain UK's excellent international reputation of being an open, welcoming and multicultural society, qualities that helped build one of the strongest economies in the modern world. Competing interests: None declared
Introspection 21 September 2007
Debashis Bhattacharya, Specialist Registrar, General Surgery North Western Deanery Send response to journal: Re: Introspection	I read with interest, both articles and really enjoyed the debate. I have simple clear cut views on this matter. The first is to improve and strengthen our training, so that there are no questions. This will include both personal and professional development. The United Kingdom is today in the middle of a tug-o-war. There are essentially three categories of aspirants. 1. UK graduates 2. Commonwealth graduates 3. European Union graduates. One way of improving standards is to encourage competition. This will only be possible, if the huge amount of security that a British Medical Graduate or a European Union graduate has regarding jobs is lifted.Innovation will be fostered and we shall leave behind a better Britain for our children than what we expected to. Obviously, a system needs to be devised, whereby we are able to quantitatively measure aptitude and rate all graduates by the same scale. I am sure this is being devised in one of the hallowed laboratories of the United Kingdom. Competing interests: None declared
Right for training positions 22 September 2007
gopalakrishna s chinnari, FTSTA in Psychiatry Glan clwyd hospital, Bodelwyddan, LL18 5UJ Send response to journal: Re: Right for training positions	I agree with Mr.Byrne's comments about reserving training places for UK graduates. But at the sametime UK government encouraged overseas graduates, for supplementing the meical work force, more so in the last decade. I think they have an obligation to provide equal oppurtinity to training positions. Competing interests: None declared
Not as simple as it appears 22 September 2007
Vivek A Furtado, ST3 Leeds Partnership NHS Foundation Trust Send response to journal: Re: Not as simple as it appears	I read with great interest the article by Edward Bryne. As the title states I must say that the issue isn't as simple as it seems. A distinguishing fact must be made between this year and the years ahead. The United Kingdom is a signatory to the EU and is therefore bound by employment laws of the EU. To prefer UK candidates over other EU candidates would contravene EU laws and therefore would not be an option (unless one decides to battle it out in the EU courts). It would have been a good idea, but considering the recent case1 wherein a german resident was awarded a higher than normal local benefits package in Bulgaria (based on EU laws), I dont think it would stand in the court of law. With regard to candidates coming from countries other than the EU, plans can be put in place henceforth onwards but those who came into the country prior to the new rules should be treated at par with EU candidates. To go back on ones word and promise isn't good for the National Health Service which has built up a reputation over the years. The third and most important are practicalities. Foreign trained medical graduates provide invaluable service to the NHS over the years. Having worked in the NHS for 2 years, I am of the opinion (although I could be very wrong since I have no data to support my claim) that recently, most locums at the junior doctor level are done by foreign trained graduates. With a drop in influx of foreign trained graduates, there would be a difficulty in filling locum slots and I am left to wonder how such locum slots would be covered. I have a nagging suspicion that the system will surely rotate a full circle in a few years time and wonder if Edward Byrne would stick to his view on the matter. Time will tell. References - 1. http://www.metro.co.uk/news/article.html?in_article_id=66819&in_page_id=34 Competing interests: IMG - arrived before the chaos
Scapegoats 22 September 2007
Jayaprakash Ayillath Gosalakkal, Consultant Paediatric Neurologist University Hospitals of Liecester Send response to journal: Re: Scapegoats	There is a move in the establishment to make the international medical graduates the scapegoats of the MTAS fiasco .To us it is clear MS Hewitt and her advisers like Lord Warner grossly miscalculated the training needs of Local graduates. There was a mismatch between available local candidates and jobs. If the line is that this was due to International medical graduates those taking that line have the responsibility to show how many IMG were preferred to local graduates by any deanery. It would be facile to first reserve all seats for local graduates and then, with an aging population, after a few years find you need more doctors and nobody answers your desperate call. For all the sugar coating this statement reeks of xenophobia when the rest of the world including Australia, USA etc are enriching their ranks with merit wherever they can find it. A Government probably also has the responsibility of providing the best manpower which is available and that may come with a different coloured passport Jayaprakash A gosalakkal UHL Leicester President UKAID Competing interests: None declared
Training of UK graduates must not be wasted 24 September 2007
John Bache, Consultant in Accident and Emergency Medicine Leighton Hospital, Crewe, Cheshire, CW1 4QJ Send response to journal: Re: Training of UK graduates must not be wasted	It is astonishing that neither Edward Byrne nor Edwin Borman mention patients in their opinions. We must not forget that we are training doctors to treat patients and in the UK in 2007 that effectively means in the NHS. The NHS is exceedingly complex and five years' apprenticeship in a British medical school must provide a basic understanding of its innate idiosyncrasies, together with a grounding in the colloquial use of the English language. Both these must be advantageous to future patients. Competing interests: I have two competing interests. I have a daughter who has worked extremely hard for many years to become a doctor, and I have funded training in British medical schools through my income tax contributions. I do not wish either of these to be wasted as a result of political correctness or political incompetence.
Do Surgical Fellowship Programmes in the UK have a quality control? 24 September 2007
Chelliah R Selvasekar, Specialist Registrar in Colorectal Surgery Christie Hospital NHS Trust, Manchester M20 4BX Send response to journal: Re: Do Surgical Fellowship Programmes in the UK have a quality control?	I read with interest the debate on ‘should the post graduate training in the UK be reserved for UK graduates’.1 Modernising medical careers is aimed at producing highly trained specialists by competency based assessment and training. The training is based on the ability to perform duties effectively and efficiently rather than the amount of time spent in a training period. There have been, as we all know, teething problems with the implementation of this programme. With the European working time directive implementation to 48 hours of working time by next year, it is even more important for a structured programme in surgical education. In surgery it will become the norm in future for surgical trainees to undergo a fellowship programme to fine tune in specific areas in a reputable institute. I was fortunate enough to undergo established fellowship training in colorectal surgery at the prestigious Mayo Clinic. The programme is well structured and is regularly assessed by the Accreditation Council for Graduate Medical Education (ACGME) for quality control. All accredited fellowship programmes in the United States of America have to be ACGME certified to be considered a worthwhile experience. At the end of the fellowship programme the trainees feel competent to perform procedures and deal with complications effectively in a safe manner. In the UK, we see more of these fellowship programmes cropping up in well established surgical units. I am not aware of any regulatory body which identifies the training needs or monitors the achievements during this training period in the different specialities in surgery. As we try to follow the American system in the modernising medical careers, we may have to follow the same for the fellowship programmes and the Royal Colleges probably have to take a leading role in recognising and certifying units where these fellowships are available and have a role in implementation. Currently trainees get into these fellowships to gain super speciality experience but it is not clear if they achieve it and what the facilities are available for the efficient delivery of the programme. I strongly feel that the Royal College of Surgeons need to take a leading role in formalising these programmes and have clear guidelines about the way the hospitals go about implementing the programmes. The trainees who have undergone fellowship training should be able to able to offer something special to develop the unit where they are appointed rather than just undergo a period of training without having gained much. Therefore I feel there is a need for quality control assessment prior to setting up these programmes and audit procedures in place to regularly scrutinise the training to make it a worthwhile experience. Hence we should be more open, have a competitive entry, encourage international trainees to compete for the training posts and establish international exchange programmes to improve the surgical training and produce broad minded trainees with contemporary skills in the future rather than close the doors for international graduates. Reference List 1. Byrne E. Should postgraduate training places be reserved for UK graduates? Yes. BMJ 2007; 335: 590. Competing interests: None declared
Workforce planning a wicked problem 24 September 2007
E Hassen, SASG NE Wales NHS Trust, LL13 7TD Send response to journal: Re: Workforce planning a wicked problem	There seem to be several peculiar assumptions underlying the arguments made: • Workforce planning is a science • The future will be like the past • Change is easy • Equity matters • Cost is not a consideration • Consequences can be accurately vectored People make decisions that serve their own perceived interests; governments do the same. Should UK graduates be preferred? Yes, that is fair. Should foreign graduates be locked out? No, but the rules should be stated clearly and commitments already made should be honoured. Competing interests: None declared
Three reasons to give priority to UK graduates 24 September 2007
Usama Alkhaddour, ENT Staff Grade Derbyshire Royal Infirmary , Derby DE1 2QY Send response to journal: Re: Three reasons to give priority to UK graduates	Although I am a non UK graduate, I believe that priority should be given to UK graduate for the following reasons: Firstly, those graduates invest huge amount of time and money and provide good business to UK universities, to be qualified as doctors. They,therefore, deserve to be rewarded and given priority when applying for training posts. Secondly, practising mecicine has a cultural aspect, especially when it comes to communicating with patient. By far, UK graduates would be more competent in understanding paient's wishes and concerns. Thirdly,employing non UK graduate was a need when there were not enough local graduates .Now that there is an increase in the number of UK graduates, the need for others has gone. I think it is not unfair to give priority to UK graduates. Competing interests: None declared
Manpower 25 September 2007
Jayaprakash Ayillath Gosalakkal, Consultant Paediatric Neurologist UHL Leicester Send response to journal: Re: Manpower	There is a misconception that IMG have managed to take away jobs from local graduates. I recently received a letter from a retired Asian GP who stated " We considered ourselves as medical missionaries in the sixties .We went where nobody else was willing to go”. I would like to see some statistics to show that IMG has ever been preferred over local graduates. They have always filled the gap. What was "De Facto" has now become "De Jure". The NHS is no more complicated that the US or other systems. Many IMG have acclimatised and thrived in such situations. I think this is just another non-issue because local graduates have always been preferred to IMG COI: Am also a taxpayer and have children in medical school here whose interests are probably best protected by such reservations for local graduates and when did meritocracy become political correctness? Competing interests: None declared
Tricky One 27 September 2007
Tim E C Bushell, retd GU Phys. St Richard's PO20 7AT Send response to journal: Re: Tricky One	I am quite sure that the UK/NHS owes its first duty to those who have spent years and Łthousands on training through to full qualification in the UK. The numbers of future doctors required should more or less balance those going to medical school: otherwise there is a scandalous waste of lives, years and money. The lousy new, untested system is a secondary scandal. I still greatly respect the position of those who've trained overseas; while we should not thoughtlessly rob poorer countries of those talentd individuals they've trained and need. Competing interests: None declared
Practice exchanges 28 September 2007
Stephen Cohen, General practitioner Busselton Western Australia 6280 Send response to journal: Re: Practice exchanges	I read with interest the discussion, in your journal, regarding overseas medical graduates taking up UK training posts . I would like to raise an issue influenced by some of the same sentiment. The status of the General Practice exchange. I am an Australian graduate (UWA 1982) and have had the pleasure of working in the UK on three separate occassions. In 1985-6 when I trained in Anaesthesia ,in Bath , I was welcome because I was young and the NHS relied on "colonials". I came back in 1997 and ,again, last year, for six month practice exchanges. On each ocassion negotiating the red tape was a nightmare and very nearly de-railed the exchanges. The red tape was however very different each time. This is a great pity as exchanges are of enormous benefit to both the exchanging doctors and their colleagues left behind. Not only is a lot learnt but the envigorating effect of a novel experience cannot be under- estimated. I am fortunate to work in a practice that encourages exchanges and can assure you that I and my colleagues have loved hosting , appropriately trained ,overseas doctors. Surely anything that maintains the enthusiasm of our experienced GP's and keeps them in active practice is to be encouraged. Unfortunately GP exchanges are threatened by workforce protectionism on several fronts, often using the excuse of maintaining standards as justification. It would be wonderful to see some mutual recognition of qualifications and experience between Australia and the UK to facilitate exchanges. Competing interests: None declared
Sham! 20 October 2007
Sunil Kumar, Specialist Trainee in Acute Medicine Leeds Teaching Hospitals Send response to journal: Re: Sham!	Having read the article by Edward Byrne and the ongoing debate I cannot help but notice that the author himself is not a UK or EEA graduate. What is today a reservation for training positions is likely to be tomorrow a reservation for trained positions( Consultants). Would the author be willing to lose his positon for to a UK graduate? Having lived and worked in the UK for the last 3 years I too have displaced my family from its roots. I too contribute to the tax as do UK graduates. I too have spent a fortune in investing in a property as a UK graduate would. Can the author surely say that I have denied a UK graduate of a training place? I pose this question to all whether they themselves would like to be treated by a competent doctor or a british national? Traditionally, IMG's only got places that a UK graduated did not want. This was an unwritten fact and whether one likes it or not, this is what has happened. The government states that it belives in equality. How could it say that when it is openly today trying to favour UK graduates. Let the competion be based on merit. May the best man(or woman) win! Isn't that what we teach our children? Be fair, be just and do not look down on people based on colour, ethinic origin etc. Yet, isn't that what is being debated here? This whole fiasco is an unfortunate meltdown of the government policy and a scapegoat is being sought! Competing interests: None declared
It should be fair 21 October 2007
Sandhya Gaur, SHO Brook Haven, B61 0BB Send response to journal: Re: It should be fair	I feel that the current crisis has been brought on by ineffective workforce management .Over the years IMg's have formed an important part of the NHS and continue to do so even now,passing through as many hurdles as there can be.I think it will be very unfair to replace IMg's already in training with new candidates from the EEA . The policy makers ought to maximise chances of UK graduates getting jobs but replacing IMg's with candidates from EEA wil not be able to achieve this. Also IMG's have to get through many possible hurdles to get a post ,the visa process is tedious and costly enough. we moved to the UK to get ourselves the training we have worked hard for and continue to do so,we too deserve a safe future . All these factors should be taken into account as it can have devastating consequences for many of us. thanks Competing interests: I am a junior doctor in training in the UK
Very Disappointed 21 October 2007
M S AFZAL, FTSTA 3 ACCS NEW CROSS HOSPITAL WOLVERHAMPTON Send response to journal: Re: Very Disappointed	I will write the same lines and talk about same issues which every body is talking about but as a human being i have given best of part of my life training and and working for the betterment patients in NHS and can safely say gain nothing except the fear of becoming jobless any time. When i looked backward i standing exactly at the same place where i left my country for higher training even getting training for almost 4 years in UK which i could have done better in other competitive countries. So if DoH wants to give all training posts to UK graduates its fair enough, but what about our contribution in managing patients paying taxes and helping NHS in achieving its targets? It's just a matter of time when all HSMP doctors will start applying for indefinite leave and start applying again for training jobs so what will DoH do at that time ? school of thought. Someone needs to take practical and long lasting decisions at this time for the betterment of health profession. Competing interests: None declared