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PLAB and UK graduates’ performance on MRCP(UK) and MRCGP examinations: data linkage study

BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g2621 (Published 17 April 2014) Cite this as: BMJ 2014;348:g2621

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Re: PLAB and UK graduates’ performance on MRCP(UK) and MRCGP examinations: data linkage study

Dear Sir,
Prof. McManus and Mr Wakeford analysed data from PLAB and MRCP(UK) and MRCGP examinations and have shown that PLAB graduates do worse than UK graduates in post-graduate examinations [1].

I have a few questions for the authors, and would also like to make a few comments.

1) A significant proportion of foreign doctors passing the PLAB examination go on to enter surgical specialities. Did the authors consider including the surgical specialities? Were the surgical Royal Colleges contacted?

2) Of all the PLAB graduates, what proportion went on to sit the MRCGP examination?
The authors have divided the PLAB graduates into 12 equally spaced groups based on their PLAB performance. It would be interesting to know whether the doctors going on to appear for the MRCGP were equally distributed in the 12 groups? If not, in which part of the spectrum were they more likely to be in?

3) 65,115 candidates had taken at least one part of the MRCP(UK) and MRCGP examination between 2001 and 2012. Only 37329 (57%) had a GMC number. How can this be explained. Did the authors look at the large percentage of doctors who sat for the MRCP examination, but never apparently worked in the UK? Intuitively, these data do not appear correct. Did the MRCP(UK) organisers have an opinion on this?

4) Of 24851 PLAB graduates, 15323(61%) did not take either the MRCP(UK) or the MRCGP examination.
This study therefore looked at the career progression, of at most 40% of PLAB graduates. This point is important, as the study findings cannot be generalised for all foreign doctors and also across all specialities.

5) Demographics of candidates taking the MRCP(UK) and MRCGP examinations : There was a significant difference between the ages at which UK graduates and PLAB graduates took the various components of the MRCP(UK) and MRCGP examinations.
This difference (of more than 4 years) is not only statistically significant, but also (for lack of an alternative word) “clinically” significant. This age difference might simply explain the difference in the performance at the postgraduate examinations.
The raw database should be analysed for the performance of UK graduates at different age levels. It is very likely that even among UK graduates, those who sit the postgraduate examinations at a later age would be performing poorly compared to those sitting the examinations at an earlier age (i.e. nearer to the time of graduation).

6) The authors make an assumption that if UK and PLAB graduates are outcome equivalent then the simplest of predictions is that their mean scores on the MRCP(UK) and MRCGP assessments should be the same.
This is the fundamental assumption of this paper, but unfortunately this is wrong. The performance in any sequential examination would be determined largely by the training and education received in the 1-2 years before sitting that exam. Most of the UK graduates would have been in hospital posts, recognised for training by the local deanery, and with protected time for education. On the other hand, the vast majority of PLAB graduates would have been in non-training posts (e.g. Clinical Fellow jobs) without access to protected teaching time or formal education.
For this study to be at all meaningful, there should be data about the jobs performed by the PLAB graduates in the intervening period between passing PLAB and appearing for the various components of the MRCP(UK) and MRCGP examinations.

7)I would suggest that if you looked at a cohort of UK graduates who did non-training jobs after graduation or after their FY2 years, their performance would be significantly worse than those of UK graduates in “training” jobs. This would also prove the basic assumption on which this paper is based as wrong.
8) Table 4 shows the mean (and SD) marks of UK and PLAB graduates at their first attempts at the various parts of the MRCP(UK) and MRCGP examination. It would have been better if you had compared the scores of only those candidates who had passed the examination. Failure in these examination would be an impediment to future career progression, and therefore the candidates would have to re-sit the examination (after another period of studying), or give up their chosen career path. Therefore, the scores of candidates who have passed this examination should be compared. I suspect the differences would not be significant. That would act as a reassurance to the NHS and medical establishment, and would prevent the kind of media frenzy, that this paper has generated in some sections of the press [2].

9) This paper also brings out a very important and significant finding. The graduates of Cambridge and Oxford have performed significantly better at the postgraduate examinations, and this perhaps is a reflection of the kind of school leavers, these institutions attract, and also their teaching methods. There is a significant variation amongst the performance of graduates of different medical schools. Should the medical schools at the lower end of the spectrum raise their bar at the exit examinations, so that the graduates they produce are equivalent to those produced by Universities at the top end of the spectrum? If this has been proposed of the PLAB examination, surely the same should be considered for the UK Universities.

I have a few other comments related not specifically to your methodology and results, but generally about the International Medical Graduates (IMGs), or foreign doctors in the UK.

Most of the locum posts (short-term, unsocial hours, or geography) are filled by foreign doctors. In our department, (Cardiothoracic Surgery, Edinburgh), we are very reliant on locums in the middle-grade rota. In the last five years, I have not seen a single UK graduate available for these locum posts. They have all been foreign graduates. While I have come across many criticisms (some justified, some not) of locum doctors in the popular media, I have never seen any mention of gratitude for these doctors, who by actually turning up, allow for our services to exist (in a legally compliant fashion) and allow us to provide emergency services to the local populations.

Previous studies have shown that the performance of foreign doctors does not result in detectable differences in mortality. Like the UK, the US is also heavily reliant on foreign doctors. Similar concerns about the performance of foreign doctors have been raised in the US. In the clinical setting, however, there has been no evidence of patients suffering as a result of being cared for by foreign doctors. In fact one study showed that patients of foreign doctors had a lower mortality than those of US doctors (graduates of US medical schools) [3].

Along with a medical student, I analysed the publicly reported mortality outcomes of all cardiac surgeons in the UK in 2013. The outcomes of the International Medical Graduates (from outside Europe) were significantly better than those of UK graduates or European graduates. (This study has not yet been published, but I would be willing to send the paper to anyone interested). [4].

And finally there is another way to interpret this data. The PLAB test is set at a level which is equivalent to a UK graduate at the FY1 level. Therefore PLAB graduates and UK graduates are equivalent at that stage. Three to five years down the line, the performance of IMGs is significantly worse than that of UK graduates. This could be due to lack of proper training, and teaching opportunities in the UK, for the foreign doctors.

It is a well-recognised fact, that the NHS is very reliant on foreign doctors. Many departments (across many specialities, and across many regions) would have to shut down if a regular supply of foreign doctors was not available. And therefore it is the responsibility of the NHS to provide significant extra resources for the education and training of foreign doctors who pass PLAB and work in non-training jobs. The reason for doing this is just not to help the foreign doctors, but more importantly because the NHS hospitals and patients will be relying on these doctors in future years.

Yours sincerely,

Vipin Zamvar

zamvarv@hotmail.com

References:
1) PLAB and UK graduates’ performance on MRCP(UK) and MRCGP examinations: data linkage study. I C McManus, R Wakeford. BMJ 2014;348:g2621.
2) Half of foreign doctors are below British standards. www.telegraph.co.uk/health/nhs/10773857/ accessed 18 April 2014.
3) Evaluating the Quality of Care Provided by Graduates of International Medical Schools. Norcini JJ, Boulet JR, Dauphinee WD, Opalek A, Krantz ID, Anderson ST. Health Aff (Millwood). 2010;29:1461-8.
4) Cardiac Surgical Results in the UK: What do the numbers reveal? Yeung E, Zamvar V (Unpublished)

Competing interests: No competing interests

20 April 2014
Vipin Zamvar
Consultant Cardiothoracic Surgeon
Royal Infirmary of Edinburgh
Little France Crescent, Edinburgh EH16 4SU