We would like to thank the people who have taken time to submit responses and broaden this debate.

Firstly, it is important to distinguish between postgraduate training and postgraduate examinations. The first we agree with, and believe it can aid retention of health professionals within their country of training. The second we disagree with when imported from the UK, rather than created, aligned with and owned by the local training system. The “Yes article” by Muir and Thacker confuse the two terms by citing a number of studies which show that doctors’ decisions to emigrate are influenced by the search for postgraduate training. This is different from emigrating in order to take UK membership examinations. Therefore, these studies cannot be used to support their argument that running UK exams overseas will aid retention. On this note, we would like to find out whether the Colleges have plans to set up postgraduate systems to support membership-certified doctors or require them to take part in revalidation of their competence as is currently being implemented by the UK General Medical Council?

Secondly, we would like to re-emphasise that UK membership exams will be of some relevance in other countries. What we stress is that a large proportion of the exams will not be useful locally. Clearly countries differ in their disease burden and health system structure. So if an exam is equally relevant in another setting, then we would argue that it is not adequately serving either the UK candidates or the overseas candidates as a certification of specialist competency. As Professor Jane Dacre of the Royal College of Physicians recently pointed out in The Hindu newspaper (http://www.thehindu.com/education/article2728873.ece), the MRCP is “a UK-based exam” and “the cultural issues such as the need to learn English or Scottish law to be able to pass an assessment in the UK should not be necessary for international candidates." Knowledge for knowledge’s sake is admirable, but studying for these exams carries large opportunity costs in terms of the financial and time commitment taken to pass them, in already overburdened settings.

Despite rapid responses from various Colleges, we have yet to hear a strong argument why the Colleges cannot use their expertise to support local postgraduate training and examinations, rather than running their own. These exams would be geared towards the local context, yet they would be informed by the Colleges’ vast experience in running high-quality examinations. Professor Dacre states that “in the long-term our objective would be to introduce more locally specific conditions for candidates to be tested on” A more efficient approach would be to help improve the robustness of exams already based on locally specific conditions by working with country training bodies. We also invite Drs Muir and Thacker to provide evidence to support their statement that UK exams have “provided a springboard for the development of local postgraduate training” or that they are better than a local exam in improving clinical standards of care.

In response to the RCP’s assertion that more candidates will lead to greater statistical reliability of examinations, this makes the assumption of a uni-modal distribution. Given the acknowledged differences in postgraduate training in partner countries, this is unlikely and including another group of candidates with a different base level of knowledge and skills is likely to decrease statistical reliability by introducing a bi-modal or non-parametric distribution. We would, however, welcome any data on the relative number of attempts by candidates from different countries and examination centres.

Finally, we find it difficult to follow Muir and Thacker’s assertion that donor organisations must fulfil the requests of the recipient without question. Any intervention by an outside organisation in a foreign country carries a responsibility. The College cannot simply devolve responsibility for their actions if asked to do something by another party. In this way, we were surprised to see the Paris and Accra declarations on aid effectiveness cited in support of this argument, given the difficulty of a recipient country “owning” a foreign exam. Independent robust postgraduate training is owning a solution.

Kate Mandeville and Delan Devakumar

kate.mandeville@lshtm.ac.uk

Competing interests: None declared