PLAB and UK graduates’ performance on MRCP(UK) and MRCGP examinations: data linkage studyBMJ 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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Graduates from the UK are not required to take any exam before applying for registration with the General Medical Council. The study does not actually compare two groups in terms of their performance in PLAB but it compared them in MRCP (UK). Concluding from this study that PLAB is in any way inferior to check eligibility of a foreign doctor to practice in the UK is not factual. Opportunities to PLAB route candidates are generally far less than UK graduates and many of the PLAB passing foreign doctors end up in non-training jobs for quite long time before getting, if any, training post. In comparison, The United States Medical Licensing Examination (USMLE) is requirement for all medical graduates inside and outside United States before being allowed to practice medicine in the US. It enables all candidates to be checked regardless of the country of primary medical qualification (PMQ). It will be more appropriate to suggest that all UK graduates take PLAB and then compare the results of two groups. Even better, if GMC makes PLAB a requirement for full registration regardless of country of PMQ.
Competing interests: No competing interests
Correlation does not mean causation. One would have thought that this is one of the basics a researcher learns early on. The authors of this paper (one professor, no less) seems to have missed this lesson. So have the BMJ reviewers and the Editor. After some years of effort the previous Editor and the current one have managed to position the BMJ so that it now occupies a zone between a medical journal and a broadsheet. It is only a matter of time before the BMJ will be the broadsheet devoted purely to medical topics.
Competing interests: No competing interests
What does the NHS want from its doctors? Why do the indigenous doctors fly away?
In this debate, the NHS has remained silent.
Why do the natives run away? Modernised Medical Careers? Too little money? Obscene working conditions? A straightjacket of protocols, best practices, tick the boxes and never mind the individual patient?
The SKYPE recruits from india. According to press reports, these angels will bypass the normal checks, such as PLAB. All doctors, whether from Oxbridge or Timbucktoo can be, rightly or wrongly, accused of medical negligence. WILL THESE DOCTORS HAVE TO. PAY EXTRA FEES For MEDICAL DEFENCE? OR , WILL THE HUMAN RESOURCE DEPARTMENT OBTAIN EXTRA FUNDS FROM THE EXCHEQUER?
Mr Buchanan has been worried about the morality of taking doctors away from the land of their birth. I presume he is equally saddened about a Rhodesian born who runs the English NHS, a South African born who wins the presidency of the College in Lincoln's Inn. I for one respect Dr Livingstone (of the I presume fame) who gave his life for the natives of Nyasaland. He could have served the sick of Scotland instead.
Mr Buchanan bemoans the lack of decent medical manpower planning. Perhaps he is too young to remember that even in the good old days, UK trained doctors were constantly sailing forth to wherever the Union Jack fluttered in the breeze of the Empire. Certainly we could do decent planning even now. Provided that we adopt a Maoist government. Unlikely.
One other point. Doctors from Hungary, Poland, Romania speaking good English, qualified from medical schools in Europe and therefore, by definition, good clinicians, are often here. Sometimes flying into do a couple of days work every week or so. Why did the NHS choose to Skype Indians instead of East Europeans? Just curious. Perhaps cheaper, more compliant labour East of Suez?
Competing interests: Old man, needs NHS treatment from competent doctors of any colour, origin , with acceptance in the UK on equal terms with the natives.
The safest drivers are those that pass their driving test on the second attempt. If a doctor has to revise twice, over a prolonged period of time I would wager his long term knowledge retention would be better than some caffeine-sodden manic reviser who hobbled over the line first time.
The questions in MRCP are bizarre to say the least. The majority of questions revolve around the small print posted at the bottom of the eponymous syndromes chapter of an archaic medical text. (I exaggerate only a little).
There are two methods of bypassing these peculiarities imposed by the Royal Colleges. Firstly; ingest the contents of Oxford Textbook of Medicine in its entirety. It has never been attempted but I am convinced it would work. The second is to methodically work your way through 6000 questions found on any number of medical websites. You will not have the desired background understanding but you will be trained in how to answer these types of questions. You will be able to see recurring themes emerge. You will even be able to answer the exact same questions in the exam. I wonder how aware IMGs of this 2nd tried and tested method.
Finally, it’s important not to infer institutional racism because of the subject matter of this paper. Similarly, I think it’s patronising to comment about the contribution of IMGs to the NHS, as if they’re a sticking plaster covering up superficial defects. They are the real deal, our colleagues and friends.
If only they were as bright as us... (joke).
Competing interests: No competing interests
We read the article by McManus and Wakeford with interest (McManus & Wakeford, 2014). It raises many interesting issues. We note the significant differences in MRCP and MRCGP results between PLAB graduates and UK candidates; these are most marked in the later or more clinical elements of the exams (PACES and CSA). The earlier parts of MRCP and the AKT of MRCGP will reflect knowledge, and candidates can acquire this through hard work. The clinical skills-based examinations (PACES and CSA) will also be influenced by the teaching and feedback candidates receive during their postgraduate training.Is it possible to see how significant that difference is?
We have recently completed a study of examination performance in the Final Fellowship in Clinical Radiology (FRCR) (in press Hawtin et al). This examination is similar to those studied by McManus & Wakeford, in that it is the final clinical skills examination to certify the completion of core training. Unlike the MRCP and MRCGP studies, we have shown no significant underperformance in black and minority ethnic candidates who train in the UK.
We should like to make two points. Firstly, we agree with McManus and Wakeford that the lower success rates of the PLAB graduates in MRCP and MRCGP may, in part, be due to the ‘educational deprivation’ that is described in the paper (the inverse care law). In radiology, all successful candidates (UK and PLAB graduates) enter a nationally-recruited training programme with common training for the first 3 years, and defined core competencies. As McManus and Wakeford comment, this is not necessarily the case with training in preparation for the MRCP examination, and there may be variation in the quality of training for international medical graduates with regards to the MRCGP. We acknowledge that clinical interaction with patients does not form part of the FRCR examination, unlike the MRCP/MRCGP. Secondly, in an earlier study (Yeung, Booth, Jacob, McCoubrie, & McKnight, 2011) attendance at an examination preparation course was associated with a higher pass rate at FRCR - it would be relevant to assess candidate performance in MRCP and MRCGP in this context.
Hawtin KE, et al., Performance in the FRCR (UK) Part 2B examination: Analysis of factors associated with
success, Clinical Radiology (2014), http://dx.doi.org/10.1016/j.crad.2014.03.007
McManus, I. C., & Wakeford, R. (2014). PLAB and UK graduates’ performance on MRCP(UK) and MRCGP examinations: data linkage study. BMJ (Clinical Research Ed.), 348(April), g2621. doi:10.1136/bmj.g2621
Yeung, a, Booth, T. C., Jacob, K., McCoubrie, P., & McKnight, L. (2011). The FRCR 2B examination: a survey of candidate perceptions and experiences. Clinical Radiology, 66(5), 412–9. doi:10.1016/j.crad.2010.12.005
Competing interests: No competing interests
Do you know the capital of The Comoros?
Yes, you do. Here is the proof:
What is the capital of The Comoros?
B New York
Not difficult really. This is the sort of “testing” you get when sitting the PLAB examination. Actually the above example at least is unambiguous. Judging by the specimen questions posted by the GMC the difference between the examiners who set the specimen tests and the examinees is a few marks. To quote one of the examiners (as displayed on the GMC site): “I have found the exam to be very fair and consistent. My initial worries about examining material outside my specialty have proved to be unfounded as I have found that there is enough information provided to enable you to cope with this. This has also made me revisit some of these areas after the exam which has made me a better examiner.”
Even a precursory look at the 30 published questions shows major deficiencies. Here we have a combination of inane questions (No.s 7, 12, 13, 17 and 22) with problems which would defeat experts in the field. Thus question No. 4 makes it virtually impossible to differentiate between Fanconi anaemia (which frequently combines with acute myeloid leukemia), a variant of acute myeloid leukemia (with no blast cells in peripheral blood plus features of haemolysis). All these conditions are anyway extremely rare - as is idiopathic aplastic anaemia (perhaps meant by the authors of the question) and is made even rarer by its rather atypical presentation. Paucity of information is characteristic of most of the questions. This does not stop the examiners from dishing out useless *vignettes” as demonstrated in question No. 14 which must be quoted in full:
14. A 32 year old woman has had a febrile illness and swelling of the small joints of her hands, feet, wrists and knees for two days. She has a maculopapular rash and a few palpable, small cervical lymph nodes. She was previously well. There is no history of relevant travel outside the UK. She has two young children.
What is the SINGLE most likely diagnosis?
Whether knees should be classified as small joints may be debatable. Does it sound like symmetrical polyarthritis? Very likely. Does it help you to know that the patient has two young children and has “no history of relevant travel outside the UK”? Your guess is good as mine. Do not hold your breath: this is supposed to be reactive arthritis.
Do you know the difference between comatose and semiconscious? According to question No. 20 there is none.
One could go on and on. Only a handful of questions seem to be reasonably constructed. Compared to USML (US licence) examination it is a very poor show. Not that the US counterpart is devoid of political correctness. In common with its British brother it avoids disclosing ethnicity in the case histories. Neither of the exams tests understanding and ability to solve problems nor delve into fundamental problems of the present medical force (namely substandard avoidance of errors and blind reliance on investigations). To mention that the basic sciences are the real Cinderella of the present medical education would be to state the obvious.
Perhaps the next step in the name of “objectivity” will be to dispense with examiners altogether and use some form of “virtual” assessment. The ability to take a qualified guess and pattern recognition is vital in passing this sort of examination. Thus the modern medical student (or a PLAB candidate) can be seen “doing” countless tests, role playing, dummy OSCEs etc. It remains to be seen whether it is an actual change for the better. I personally, as a “client” prefer doctors who are qualified the old-fashioned way: answering open-ended questions and examining real patients. Perhaps it is also old fashioned to think that non scholae sed vitae discimus.
Competing interests: No competing interests
The article does have certain serious flaws.
First the author does not use the actual mean score to come to his conclusions. He says that analyses based on marks attained at passing are more complex and have skewed distributions. Complexity of data is no excuse to chose whatever data set you like. Specifically since he has not mentioned the Mean marks at all.
Now the average difference between the cohorts for MRCP Part 1 exam is given to be 9 marks approximately. Since the exam is marked in 999 marks that would only amount to a 1 percent difference between the cohorts. To state that 80 percent of Plab graduates are inferior to the lowest UK grads based upon this difference seems to be a bit extreme.
Second it uses a subset which is not random and hence not representational.
Third it uses a small number of exams to prove its point.
Fourth out of those exams, the authors use only one exam to draw their conclusions. The authors freely agree that their method when applied to the other exams did not generate a meaningfull output.
This scarcity of sampling is precisely the kind of bias which led to fiascoes like the Oseltamivir incident.
BMJ would do well to reassess the study and if necessary add additional information.
Dr R Unnipillai
Competing interests: IMG
Further to my previous post:
I suggest to those waiting for Skype interviews for NHS junior posts -
Ask the NHS interviewers why the British-trained doctors are leaving these shores.
What study leave is guaranteed.
What is the duration of the contract.
What are the arrangements for "induction, orientation".
Who will be your mentor.
Will your interviewers meet you at your new place of work.
Will your interviewers meet you at the end of your contract.
Does the hospital where you will be working meet the minimum standards of staffing and other criteria set by the Care Quality Commission.
Has the hospital concerned been inspected by "surprise visit" by the Commission - not by mere periodic visits when the managers have had the opportunity to present a veneer of decency.
Just as you will be asked for referees, you should ask the interviewers to name referees. After all you will not have had the opportunity to make your own informal inquiries and visits.
The above might send a shiver down the spine of the NHS management. It will be, I believe, helpful to the patients as well. And after all, as doctors you want the best for your patients. The managers only want to tick all boxes.
Competing interests: Old man, seeking NHS treatment from competent staff , doctors and nurses.
The Professional and Linguistic Assessment Board test (PLAB) is the required examination for doctors who graduate from non-EU medical schools and wish to work in the United Kingdom (UK). The PLAB is an assessment of the knowledge and other competencies deemed necessary to work in the National Health Service (NHS). In recent times there has been much attention paid by the General Medical Council (GMC) to the English language capabilities of foreign medical graduates working in the UK, but little on the level of knowledge required to work in the NHS. Two groundbreaking analyses, performed by McManus and Wakeford, and Tiffin and his colleagues have brought focus on the standard of the PLAB. These data link PLAB performance with post-graduate outcomes in specialty training exams and annual competency reviews, and compared these to the achievements displayed by graduates of British medical schools.[2, 3] Both studies found that those that entered the British medical workforce via the PLAB route performed poorly, and that significantly raising the PLAB pass mark may ameliorate this.
Although the PLAB purports to assess candidates to a level equivalent to a doctor who has finished foundation year 1, in the experience of this author, the standard of the PLAB is perhaps more reflective of the penultimate year of medical school. The GMC, by its own admission, "has responsibility for setting the standards of practice in the UK" and therefore the current PLAB standard is concerning. The PLAB has two parts: the first part consisting of a written multiple-choice exam, and the second a clinical exam. It is possible to sit part 1 of the PLAB exam an indefinite number of times, and to attempt part 2 four times in the two years after passing part 1. Given the low standard of the PLAB, and the theoretical possibility of indefinite attempts at part 1, the current system encourages candidates to rote-learn the bare minimum, and try, try again! Candidates are also able to participate in a range of privately run courses, which, by their own figures at least, are able to teach almost all candidates how to pass PLAB part 2. The questions in both parts of the PLAB can be formulaic and predictable. This explains much of the success of PLAB preparation courses, which teach to test rather than teach medicine. It is also noteworthy that in 1980 60% of candidates failed the PLAB, whereas the current pass rate of the PLAB is in excess of 60%.
Others have pointed out further limitations of the PLAB system, such as its lack of equivalency with any other British or international exam, and associated with this lack of transparency in the standard of the PLAB compared with other qualifications.
In light of the new data describing a link between the PLAB and poor post-graduate performance, commentaries featuring arguments that favor raising or keeping the current standard of the PLAB have both been published.[8, 9] The key question for the GMC is: what sort of international medical workforce does the UK deserve? With its proud tradition of medical quality, innovation and training, only the best from overseas should meet the standard to work in the UK. To this end, the GMC should be encouraged to heighten the PLAB standard. In addition, candidates should only be allowed 3 attempts at the PLAB part 1 exam before a five-year "lock-out" period. This would encourage thorough, in-depth understanding of medicine prior to sitting the exam, rather than rote regurgitation of facts. Arguments that increasing the PLAB pass mark would reduce the available workforce are valid, however the GMC is responsible for standard setting, not workforce planning. Reliance on international medical graduates is a governmental issue that should be addressed through an integrated approach that spans British medical school admissions to consultant positions.
Synchronization of the UK medical licensing system with that of the United States should also be considered. Aligning 3 medical exams with steps 1, 2, and 3 of the United Stated Medical Licence Examination (USMLE) could facilitate international standard-setting and prepare for a more transparent future system where medical graduates could more easily move about the globe on the basis of a universal system of qualifications.
A final point. The real suffering experienced by doctors who pass the PLAB and remain unemployed or who struggle through training programs they are not equipped for is possibly underappreciated. While calls for “early intervention” for struggling doctors in regards to teaching communication and other skills are laudable, any intervention needs to be multi-faceted. A higher PLAB benchmark should be one facet. This would result in a lower proportion of overseas-trained doctors suffering from un- or under-employment, and less doctors entering into training programs where they are likely to fail. The current structure of the PLAB does a disservice to both overseas-trained doctors and the NHS.
1. Jaques, H. (2013) GMC is to get legal power to check English skills of European doctors. BMJ 346
2. McManus, I.C. and Wakeford, R. (2014) PLAB and UK graduates' performance on MRCP(UK) and MRCGP examinations: data linkage study. BMJ 348
3. Tiffin, P.A., et al. (2014) Annual Review of Competence Progression (ARCP) performance of doctors who passed Professional and Linguistic Assessments Board (PLAB) tests compared with UK medical graduates: national data linkage study. BMJ 348
4. Hart, M. (2007) Role of the PLAB test. BMJ 335, 1062-1062
5. PLABRight (2014) Why PLABRight. http://www.plabright.com/why.htm Accessed 23rd of April, 2014
6. (1980) Over 60% fail PLAB tests. BMJ 280, 810-810
7. Gorelov, V. (2010) UK licence to practise comes short of a "UKMLE". Lancet 375, 1591-1592
8. Peile, E. (2014) Selecting an internationally diverse medical workforce. BMJ 348
9. Moberly, T. (2014) Minority report: how the UK's treatment of foreign and ethnic minority doctors needs to change. BMJ 348
Competing interests: The author is an international medical graduate who recently sat the PLAB.
‘‘Is PLAB too easy to clear?’’
… screams the front page of the BMJ on 26.04.2014. This assertion is based on the outcome of two studies by McManus & Wakeford and Tiffin et al. The former compared the performance of PLAB and UK graduates in the MRCP (UK) and MRCGP examinations; the latter looked at the annual review of competence progression (ARCP) performance between both groups. Both studies concluded that the PLAB group fared worse hence the question ‘Is PLAB too easy to clear?’
All graduates from non EU countries bar a few commonwealth countries have to pass PLAB before gaining eligibility to practice in the UK. In the USA, all non US graduates have to sit the USMLE before being allowed to practice. The USMLE is validated by getting US graduates to sit the examination. In the UK, there is only one study where 50 UK graduates sat PLAB, only 2 doctors passed (Stewart 2003)(3). One could infer that if the same group sat the MRCP (UK), MRCGP or attended the ARCP, they would have performed better than the non UK graduates who passed PLAB.
The studies by McManus and Tiffin failed to factor in the year that subjects in the study graduated from medical school. How long did these individuals spend in dead end – non training jobs before taking the tests or how many attempted the MRCP examination from a non-training job?
PLAB is an examination aimed at foundation 2 / CT1 doctors, membership exams and the ARCP are postgraduate activities. The real question is why have these individual failed to progress in the training programmes?
These studies reflect the short comings in medical education. We propose that Postgraduate medical education needs to be better structured; the non-training posts need to be consigned to the museum. All trainees need better supervision and poorly performing trainees should receive the appropriate support before they present themselves for the exams.
In the US, a high failure rate at the board examinations would give the programme directors a lot to think about, it ought to elicit the same sentiment in the UK.
Tayo Oke Consultant Surgeon
Samuel Orakwe Consultant Orthopaedic Surgeon
Queen Elizabeth Hospital, Woolwich, London SE18 4QH
Competing interests: None declared
1 IC McManus, R Wakeford. PLAB and UK graduates’ performance on MRCP(UK) and MRCGP examinations: data linkage study. BMJ 2014;348:g9
2 P Tiffin, J Illing, AS Kasim, JC McLachlan. Annual Review of Competence Progression (ARCP) performance of doctors who passed Professional and Linguistic Assessments Board (PLAB) tests compared with UK medical graduates: national data linkage study. BMJ 2014;348:g10
Competing interests: No competing interests