Head To Head

Should UK membership exams be held overseas? Yes

BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d4566 (Published 28 July 2011) Cite this as: BMJ 2011;343:d4566
  1. Graeme Muir, examinations and assessment adviser,
  2. Justin Thacker, head of international operations
  1. 1Royal College of Paediatrics and Child Health
  1. Correspondence to: G Muir Graeme.Muir{at}rcpch.ac.uk

Graeme Muir and Justin Thacker believe that UK professional qualifications can help other countries improve training and standards, but Delan Devakumar and Kate Mandeville (doi:10.1136/bmj.d4560) argue that they lack local relevance

Critics suggest that holding UK postgraduate examinations in low and middle income countries undermines the development of domestic postgraduate education, promotes syllabuses that may not be appropriate to the healthcare needs of these countries, and encourages migration, thereby damaging local healthcare systems.1

As a responsible international organisation, we are aware of these important concerns and guard against them when working with our colleagues overseas. The development of effective postgraduate education requires quality assured assessment of trained doctors at an appropriate standard. Rather than undermine local programmes, the provision of a UK postgraduate qualification can provide a springboard for further development of local postgraduate training. We believe our exam and subsequent award of an internationally recognised qualification can contribute to improving standards of clinical care.

Training benefits

Although patterns of disease obviously vary across regions, all health professionals now exist in a global health environment.2 A key question is whether an assessment covers competences that translate to another health setting. The MRCPCH, which examines core and generic paediatric clinical skills, can be as relevant internationally as it is in the UK.

The argument that exams themselves may damage staff retention within local health systems is not supported by evidence. Several studies have examined the factors affecting retention of healthcare professionals in low income countries. George and colleagues surveyed non-European Union doctors working in the NHS and found that 76.7% cited their main reason for leaving their home country as being the pursuit of postgraduate training.3 A study by Ferrinho and colleagues analysing training and professional expectations of medical students in Angola, Guinea-Bissau, and Mozambique found that the opportunity to undertake specialist training was an important factor in students’ expectations about working abroad. They suggest “investments to create capacity to undertake specialised training can become a useful tool to control the brain drain.”4 This is supported by Oman and colleagues, whose study of migration of doctors from Fiji found that “Local or regional postgraduate training may increase retention of doctors.”5 Thus the provision of locally based high quality professional assessments provides a route for professional development in countries that should aid, rather than hinder, retention of skilled staff.

Meeting local needs

We recognise that the arguments against UK exams have merit in some countries and settings. The problem is that it is inappropriate for UK doctors to decide in which countries our support will be of benefit and where it may not. The best people to make an informed decision are the relevant professionals in that country. For example in our case, it is our partners, such as the Indian Academy of Pediatrics, whom we judge to be best placed to decide whether holding the MRCPCH is appropriate.

A series of recent international agreements has emphasised that any international development assistance must be driven by the demands of the country rather than the interests of donors. The Paris Declaration of 2005 and the Accra Agenda for Action of 2008 instituted a clear requirement for assistance to be provided in line with the requirements of recipient countries.6 The reason for this is simple. Development initiatives are more likely to be effective if recipient countries have ownership—that is, define their own national development strategies—and donor countries align themselves in support of these strategies. The Crisp report on the UK’s role in international health states that the health millennium development goals will not be met unless “developing countries are able to take the lead and own the solutions, supported by international, national and local partnerships based on mutual respect.”7 Similarly, the 2010 Framework for NHS Involvement in International Development states that aid must be “led and driven by the needs of developing countries, not by the enthusiasm and interests of UK participants.”8 Given this, we would argue that it is not for UK based doctors to determine medical education strategy overseas, but to respect the primacy of local professional bodies, who are best placed to direct training and assessment.

It is the policy of the Royal College of Paediatrics and Child Health to offer postgraduate examinations only at the request of, and in partnership with, equivalent bodies overseas. This collaboration is a joint initiative, and feedback from our partner organisations strongly supports the MRCPCH syllabus as fitting well with local training needs. As we have previously pointed out, “the UK clinical examination offers focus on a patient centred approach to clinical problem solving, a feature that naturally sits well with the high standards of knowledge and clinical skill that pervade in many overseas centres.”9 We believe that the decision whether the assessments we offer are appropriate to the training needs of doctors outside the UK, rests primarily with our international partners.

Indeed, if we were to ignore the demands of our overseas partners we would be in danger of contravening the principles set out in Paris and Accra and repeated elsewhere. Unless the situation changes or until there is more compelling evidence we will maintain our approach. Our responsibility is not to tell our partners what they need, but rather to share expertise and work with them in the common purpose of supporting high standards in medical education.


Cite this as: BMJ 2011;343:d4566


  • Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years, and no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Commissioned; not externally peer reviewed.


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