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:d4566All rapid responses
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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
Competing interests: No competing interests
We feel compelled, out of conviction rather than mere solidarity, to
support the case made in this debate (24 September) on behalf of the Royal
College of Paediatrics and Child Health by Graeme Muir and Justin Thacker
(BMJ 2011;343:d4566). Like the RCPCH, the Federation of Royal Colleges of
Physicians of the UK has responded to requests from trainees and trainers
in many overseas countries to provide MRCP(UK) examination centres. Our
written examinations are currently sat in 28 countries outside the UK and
our clinical examination (PACES) in 8. The provision of this facility does
not represent an attempt to dictate either the content or the standard of
postgraduate medical education, but acknowledges the need for an
international standard of medical knowledge and clinical practice to which
all trainees can aspire. Wherever possible, in providing an international
diploma in overseas countries, we have tried to establish a conjoint
arrangement between the MRCP(UK) and an existing national postgraduate
examination for trainee physicians. In Hong Kong and Singapore, for
instance, the MRCP(UK) examination is an integral part of clinical
assessment for middle-grade trainees.
As a means of ensuring local relevance of our examinations, our
examining boards include international representatives who take part in
question selection for every diet of our written examinations, and whose
opinions are sought about the suitability of question material for
physicians training overseas. In the PACES examination, not only is every
candidate examined by both a local physician and a UK physician, but each
examination includes clinical scenarios drafted by local physicians and
clinical cases are patients drawn from the local population with
conditions prevalent in the locality. This ensures that the examination
content is not UK-centric but seeks the knowledge and clinical judgement
required of a competent physician practising anywhere in the world. This
does not imply that a successful candidate is equipped to practise
overseas without reference to national laws, national clinical guidelines
or cultural differences as they apply to ethical decisions, merely that
clinical competence has been demonstrated to an internationally agreed
standard. We aim to support the local health economy, and are not
certifying doctors for export.
Developing a national postgraduate examination presents considerable
challenges, both academic and financial, and can often be difficult to
justify when the anticipated number of candidates is small. Another
important justification for an international examination is the effect
that inclusion of large numbers of candidates has upon the examination's
statistical reliability, which is important in establishing public
confidence.
We therefore contend, contrary to the views expressed by Delan
Devakumar and Kate Mandeville that our examinations are locally relevant
and enhance rather than undermine local postgraduate training; and they do
reflect population needs.
Dr Lawrence McAlpine, MRCP(UK) international associate medical
director; Dr John Mucklow, MRCP(UK) associate medical director for written
examinations; Professor Jane Dacre, MRCP(UK) medical director
Competing interests: The authors are Fellows of the Royal Colleges of Physicians of the UK
Any examination without substance is useless. The membership
examination conducted by the UK colleges is honestly speaking good
business for the colleges. I was amazed to discover the "pre-requisite" to sit the part II examination. It required only 3 years of hospital based
practice. It never asked for which type of practice and the type of
hospital the practice should be based in.
There was a time when the Royal
colleges would accept only experience gained in a teaching hospital in one
of the Commonwealth countries.
Then the Membership examination is the "entry point" to get further
training. With no such opportunity available for the developing countries
in the changed scenario, I believe that the Royal colleges are issuing Quackery
Diplomas to doctors and giving them a licence to play havoc with the
lives of patients in their own countries.
The Colleges should sither arrange "post Membership training" for such
doctors or they should really stop the examinations conducted outside the UK.
Competing interests: No competing interests
Dear Editor,
I read all the letters coming from colleagues all over the world
which preserve the" myth of UK medical certifications".
I suppose that Medical Colleges in Italy, Norway, Sweden, Germany,
France, the Netherlands, Belgium, Spain, Portugal, Finland, Denmark,
Poland, etc are very offended.
They read in the letters to the BMJ that vast numbers of doctors from
developing Countries choose to obtain medical certifications from the UK
in order to get postgraduate training. As if all those European Countries
were unable to issue high quality postgraduate fellowships or advanced
medical research programmes!
If language was the limiting factor, why don't these candidates
choose New Zealand, Australia, Canada, South Africa, and Ireland?
No one admits that UK medical certifications are also used to dazzle
patients, thus boosting business.
Since UK Colleges are gaining considerable sums of money by
organizing, supervising, training, testing and licensing tens of thousands
of doctors abroad, everyone is happy.
Soon there are going to be more medical doctors holding UK
certificates working in India, Pakistan, China, Africa and the Middle East
than those working in the British Isles!
The Federal Reserve cannot print trillions of new dollars every month
because ALL circulating dollars are then going to lose value.
Similarly, UK Colleges should consider if this certification frenzy
risks devaluating ALL issued by them certificates.
Competing interests: No competing interests
My perspective on this discussion represents that of young physicians
who are attracted by international medical exams. I recently sat for US
medical exam (USMLE) and some of my colleagues sat for UK membership exams
in Nepal. Our main aim was to gain opportunity to do postgraduate training
abroad.
This exam was an opportunity to understand medicine from a different
perspective. During medical practice we must meet local need and our
medical education is tailored to fulfill that objective. We are not
updated on latest developments in medicine because they are not applied in
local context. For example, we have poor understanding of clinical
application of basic science subjects like immunology and genetics which
are pretty advanced these days. Many subjects I covered for exams were not
locally relevant but we can make similar arguments about medical school
teaching in which we follow international text books and read a lot about
many diseases that are rare. That does not mean it is a complete waste to
spend so many years in medical school reading about rare diseases that we may
never encounter. As a medical practitioner it is good to have broad
knowledge about both common and exotic diseases.
Unlike medical school exam, this exam made me oriented on current
principles of medicine and helped me understand latest trends in medicine.
One great advantage was I could follow recent developments in medicine in
medical journals. In my clinical practice I encounter many infectious
disease and related complications. Infectious diseases are obsolete
subject for research and very little on these topics is covered in
international journals. But still I read and follow international journals,
not because I hope to find new medication and treatment that I can offer
for my patients, but to keep myself abreast with principles of treatment,
which are often revised, so that I can follow evidence based practice and
provide optimal care of my patients.
If such international exams and opportunity are available locally and
accessible for medical students, they will work hard and medical education
will be more competitive, which is good for local medical programs as well.
Colleges administrating such exams may receive financial gain, but it is ok
as long as both parties can benefit.
Competing interests: No competing interests
This indeed is a debatable topic and we would like to debate in
favour of making the UK membership exams open to non-UK candidates. It
would be too harsh to conclude that 'accreditations are being sold', and
that 'candidates from outside the UK gain UK accreditations so as to boost
their business'.
First of all, the standards of the exams are high and hence, only the
best happen to be successful in gaining these accreditations.
Secondly, its a very human thing to yearn for something which is
known to be coveted, and known to be of high value. After all, it is the
same beautiful human spirit that drives us to scale the lofty Himalayan
peaks, even with the unquestionable knowledge that there wont be any
material benefit out of it.
Competing interests: No competing interests
Dear Editor,
Many overseas doctors, who pay, sit for UK membership exams, and pass
them, never intended to work in the UK!
They have already successfully passed every local membership exam.
They only need the UK certificate to impress their patients, by
hanging it at a very visible place in their office.
They could also pay, sit for and pass French, German or Italian
medical membership exams. All these exams confer working rights in Europe,
including UK. Instead, they only choose UK membership exams. Why?
Because UK certificates happen to impress local patients more, thus
are better for business!
It is good business for UK Colleges too, as Delan Devakumar and Kate
Mandeville wrote. [1]
So, everyone is happy.
We should wonder if "selling" medical accreditations to doctors
abroad, who do not work in the NHS, is ethical.
Competing interests: No competing interests
Both sides in this discussion make excellent points and clearly if
holding a Membership exam within a country improves the postgraduate
infrastructure, this is an important benefit. However the financial
benefit to the administering College must also be a factor in the
equation.
Having been responsible for the Palestinian Diploma in Child Health course
since its inception six years ago, I have come to the conclusion that
working in partnership between the RCPCH and Palestinian paediatricians is
hugely valuable to both sides, and our course provides much more than
simply offering an exam could do. The College does set an exam within the
country but it is not one that would encourage graduates to migrate, and
the course is open to both doctors and nurses.
This model may not be applicable to all developing countries, but does
avoid the pitfalls which are well described by Devakumar and Mandeville.
Competing interests: I am a Fellow of the Royal College of Paediatrics and Child Health and the clinical lead for the Diploma in Palestinian Child Health
Re: Should UK membership exams be held overseas? Yes
I wonder why we are debating this issue now when UK membership exams are already being held overseas for the past many years (Part 1 and more recently Part 2/PACES).
I feel that the topic of this debate should be 'Is there a need for UK membership exams to be held overseas?' One might think that this arrangement probably is a cheaper as well as convenient option for overseas candidates. However, the fact is that they tend to spend more in terms of money, time and energy for various reasons.
There is no doubt that UK membership exam uses an assessment process which is well tested and validated. It maintains a standard which is recognised and appreciated worldwide. It also provides a bench mark for higher postgraduate training in the United Kingdom.
The Royal College of Physicians (UK) has carefully chosen overseas centres for conducting its examinations. What the doctor does after obtaining the diploma is beyond anybody's control. Finally, one must appreciate that such a valuable service cannot be offered for free.
Competing interests: I am member of the Royal College of Physicians (UK)