Selecting an internationally diverse medical workforce

BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g2696 (Published 17 April 2014) Cite this as: BMJ 2014;348:g2696
  1. Ed Peile, professor emeritus of medical education,
  1. 1Warwick Medical School, University of Warwick, CV4 7AL
  1. ed.peile{at}warwick.ac.uk

Doing it with respect is in everyone’s best interests

Two new linked studies tackle difficult educational issues concerning international medical graduates practising medicine in the UK. Tiffin et al1 report that international graduates, mainly from outside the European Union, achieve less satisfactory outcomes than UK graduates at annual appraisals known as Annual Review Competency Panels (ARCP). McManus and Wakeford2 find that they perform less well than UK graduates in postgraduate examinations for trainees in internal medicine (Membership of the Royal Colleges of Physicians (MRCP)) and family medicine (Membership of the Royal Collage of General Practitioners (MRCGP)).

Both these data linkage studies were commissioned by the UK regulator, the General Medical Council (GMC), which is considering revising the two examinations that currently determine an international graduate’s fitness for medical registration in the UK. Importantly, both studies show that the two examinations, set by the Professional and Linguistics Assessment Board (PLAB Part 1 and PLAB Part 2), predict performance in later professional assessments. They also agree that international graduates who do better at compulsory English language tests do better in postgraduate training.

McManus and Wakeford use two different approaches to quantify how much the pass marks for PLAB examinations would have to change to select international graduates who would perform as well as UK graduates. Both methods yielded similar results and confirmed the finding by Tiffin et al1 that these pass marks would have to be set considerably higher than they are now, to achieve equivalence between international medical graduates and their UK trained peers. Both teams of authors are aware of the workforce implications of their findings. If “UK equivalent” pass marks had been applied in years gone by, most of the doctors who have entered UK practice by the PLAB route, and who make such an important contribution to the NHS, would not have been allowed to enter the workforce at that level of performance. However, doctors rise to challenges with better preparation and particular attention to language skills and cultural understanding.

The “fairness” of clinical skills assessment (CSA) in the MRCGP exam was recently tested by judicial review in the UK. Mr Justice Mitting commented that the relative performance of international medical graduates could be explained, at least in part, by inferior education systems overseas.3 The new studies show that many international medical graduates who pass PLAB examinations and register to practise have not reached an equivalent standard at entry to postgraduate training to that of UK trained graduates. Differences in the performance of international and UK graduates are troubling but not new. Esmail and Roberts reported last year that international graduates were 14.7 times more likely than UK graduates to fail the clinical skills component of the MRCGP examination. They were also more likely to fail the Applied Knowledge Test (AKT) for MRCGP.4 Clearly, we need to explore these differences further.5 Discrimination, which was not ruled out by Esmail and Roberts, but seems unlikely from Denney and colleagues’ analysis ,6 would be wholly unacceptable. The NHS constitution makes clear that “Respect, dignity, compassion and care should be at the core of how patients and staff are treated not only because that is the right thing to do but because patient safety, experience and outcomes are all improved when staff are valued, empowered and supported.”7

Respect for doctors who trained outside the country where they practise demands fairness in the way their performance is evaluated. Equally, respect is promoted and bias diminished, if the assessments that international graduates must master are well reputed.8 It seems that the PLAB assessments as currently operated by the UK’s regulator do not ensure equity of performance with UK graduates. The reputation of PLAB suffers, along with that of international graduates registered in the UK by this route.

International evidence suggests that the relative performance of international medical graduates does not translate into detectable differences in patient mortality.9 10 The evidence points instead to more nuanced areas of contextual difficulty in communication, ethics, and team working.11 12

Medical educators in the UK are obliged to assess doctors’ competence in delivering context-sensitive, patient centred care in a multicultural society, in line with NHS principles of excellence and professionalism. Examinations such as the clinical skills component of MRCGP are designed with this in mind. Although its fitness for purpose has been questioned,4 6 so far the intense scrutiny seems supportive. There is a broad consensus that international medical graduates need targeted support, particularly at induction,13 and in respect of communication skills.14

Early support for international graduates should ensure we are not setting doctors up to fail. Developing better language skills is sensible, and with most medical schools demanding a minimum score of 7.5 in the International English Language Testing System this should be the level required to sit PLAB. The GMC currently demands a score of 7.0, set in 2010. The pass marks for first part of the PLAB examination should be raised year on year, aiming to reach the level of equivalence (some 13% higher than current pass marks) within four years. Pass marks in the second part of the examination should rise in parallel with a short lag time. Phased increases will help prevent undue pressure on workforce planning and allow time for educators to evaluate improvements to PLAB and consider alternative forms of assessment.

In the interests of good communication all doctors should be taught how to work effectively with interpreters. With a similar aim, guidance for doctors from the UK’s regulator will soon include an explicit statement about knowledge of English. Since inadequate English will become a distinct cause of impaired fitness to practise, language skills must be assessed rigorously before any doctor starts work or postgraduate training in the UK.

Finally, it is vital that we do not stigmatise international medical graduates. UK trained graduates can also struggle with annual appraisals and postgraduate exams, as do some migrant doctors from within the European Union. Professional assessments are there for a purpose—to protect patient safety and ensure that doctors from any background are competent at understanding and working with the values of every patient in their care.


Cite this as: BMJ 2014;348:g2696


  • Research, doi:10.1136/bmj.g2622
  • Research, doi:10.1136/bmj.g2621
  • Conflicts of interest: I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: I am a fellow of the Royal College of General Practitioners and paid fees by the college for accreditation of educational programmes; I am editor of the Journal of Education for Primary Care and occasional paid contributor to the British Journal of General Practice.

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


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