Selecting an internationally diverse medical workforceBMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g2696 (Published 17 April 2014) Cite this as: BMJ 2014;348:g2696
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This editorial and the three linked articles in this week's BMJ are thought-provoking, but require careful analysis. I wish to share some of my experiences as an 'International Medical Graduate,' and suggest some confounders in the association between PLAB results or ethnicity and performance measures, especially those based upon exams and annual reviews.
I came to the UK in 1998, and sat for the PLAB exams and the MRCP part 1 before I could apply for any jobs. Coming from Chennai, where we often spoke in English to each other, I did not find language to be a challenge while undertaking any exams, and this helped me pass all my exams in the first attempt (including subsequent MRCP exams and other professional courses).
However language and context were occasionally challenges at the workplace. One example is that a HO (a UK graduate, an FY1 in today's terms) prescribed amoxicillin twice daily, and later said that was what I had asked her to do. She had misunderstood my advice to prescribe it 'thrice daily' because only her "grandmother ever used the word thrice". Another example is that even now I occasionally struggle to understand some comments from my Scottish patients. I am sure that these difficulties would also apply (perhaps to a lesser extent) with UK graduates who move from their local area to others, especially if they did not have friends in the destination who could help them adapt quickly. However international medical graduates are the ones who move around the most, and often do not have local friends to guide them. This may be a factor in their difficulties in adapting to local language (and contextual issues in medical practice). Those international graduate who did not study in English before coming to the UK would be particularly disadvantaged in this fashion.
Adapting to accents and colloquialism was not my only challenge. Along with many of my then compatriots, I found the need for play acting during examinations to be a huge hurdle. This was an entirely new experience for me; I had never acted in a play as a child, never been to a play before, and did not have to act or deal with actors during any of my education. However I am a bit less shy than many other people who come from my part of the world, and have learned to act just enough to now be able to participate in media training, to coach registrars for consultant interviews (they got the jobs), and recently to coach a friend for the MRCGP exam (an international graduate, she passed the exam in the first attempt). The MRCGP exam certainly involves a great deal of play acting, and I believe its results are particularly sensitive to the candidate's theatrical skills. It could be argued that such skills are also useful in medical practice, but the RCGP should ask itself whether it is acceptable if weakness in acting skills neutralises other strengths that candidates may possess.
Other factors that have an impact on measurements of performance of international medical graduates despite having at best a weak effect on performance at the bedside are some shared prejudices and shared lists of causes and red flags. I remember that the one exam preparation course that I attended in the UK (for the MRCP) was full of prejudiced views, e.g. about illnesses that beset travellers to the Netherlands or people with beards! Recently I saw how some excellent candidates (UK graduates in this instance) who performed exceptionally at other stations could fail at a CMT interview merely because they did not go through a full list of causes or actions for a GI bleeding scenario. Some of the discussions around what was expected by one examiner (a gastroenterologist) made me think about some past articles in the BMJ about the value (of lack thereof) of 'red flags', and whether it was fair to fail a caring and clearly knowledgeable person because an examiner wants a candidate to reply in a particular format. This would of course have been much more challenging for any international graduates in a similar situation.
The last experience also made me reflect upon how much value we should place on these examinations and responses. Sometimes they are similar to asking a candidate at a driving test to imagine driving on a particular route and describe each step, including every change in gear and every time that they look at their rear-view mirror, while driving from point A to point B. Surely there are people other than me who can remember these details perfectly well when actually managing a patient but struggle to say all this when acting out or describing responses in a sterile room?
My CMT interview experience also made me reflect on what we want our future doctors to be - walking and talking like us, or performing like us in other more complex ways? To borrow from an article on PHE's response to shale gas extraction in the same issue of BMJ, are we 'Mistaking actual practices for best practices'? Could some of the perceived weaknesses of some international medical graduates (and UK graduates) actually be variations in approach that might be strengths rather than weaknesses?
I would like to conclude by saying that I do not disagree with the articles in this week's BMJ, but would like everyone involved to look beyond the surface for explanations, and therefore for corrective measures. Increasing the threshold for passing the PLAB exam may not be enough, but adding contextual challenges to the PLAB exam may help international candidates prepare for their work in the UK. Hospitals could also learn from Universities in how they help international students to adapt to local environments, how they welcome graduates and help them make friends. Differences are not ironed out, but perhaps spending time with local friends makes university students express their abilities as well as they can.
Competing interests: No competing interests
I am one of many UK doctors working as assessors for Clinical Skills Assessment for PLAB for many years.
There is no simple answer to this long-standing problem. Training more UK citizens as doctors is obvious but I expect it is the expense that delays this.
Having assessed hundreds of overseas medical graduates annually for many years I have observed
1 The GMC genuinely tries all the time to check and improve exam quality and remove any possible bias. This work for continuous improvement is really impressive.
2 All assessors are current or retired NHS workers and the majority are non-white.
3 Some candidates have come from a background of limited medical training with limited facilities eg they cannot correctly handle an ophthalmoscope of tuning fork compared to the abilities of a South African or Australian trained candidate.
4 Some are already specialists in their home country so a general exam may be extra hard for them.
5 So varied are the social milieu, ethical views, ambitions and abilities of candidates that for everybody's sakes they must be individually mentored for, say, a year after passing PLAB.
Lastly I would make it a little bit more difficult to pass.
Competing interests: No competing interests
The function of assessments of doctor's clinical abilities is to ensure patients get best care not to offer equal opportunities to all doctors. These assessments are of course imperfect although as far as the RCGP is concerned the court agreed that they are valid and reliable. Of course all failing doctors must get the same opportunities for further training and reassessment no matter what their origins might be.
When I examined for the GP College in the 1980s it was clear that FMGs did less well in the written and the oral components of the membership exam. There was much examiner agonising over the reasons for this but the general consensus was that those candidates who did less well were actually less well suited for UK general practice at that time. Plus ca change....?
Why does the NHS need to employ so many FMGs who are often from countries less well-off ? In doing so it deprives these countries of valuable medical resources and wipes out their previous investment in the medical education of these doctors. Is this fair?
Why cannot the UK train sufficient doctors for its own needs? I accept the desirability of international medical exchange which enriches the medical culture of all participating countries but the current NHS situation seems grossly unbalanced and unfair.
Competing interests: Potential NHS Patient.
The key background to this paper is given in the linked editorial by Tony Delamothe, Deputy Editor (BMJ 2014:348:g2894). Here he tells us that 40% of NHS doctors are foreign born and that 26% of doctors registered with the GMC qualified outside the European Economic Area.
Professor Peile rises to his challenge and suggests a reasonable solution but I assume that he was not asked to comment on the scandal that the NHS relies very heavily on overseas graduates without whom it could not to function.
Why is it not possible to train sufficient doctors for our own needs? We are one of the richest countries in the world but it seems that we must import medical talent from wherever we can find it.
Poorer countries cannot afford to train their brightest and best young people as doctors and then see large numbers come to spend all their professional lives in the U.K. At the same time many talented and caring British students are denied the opportunity to go to Medical School. Surely this must be unacceptable for the long term. There must be movement of doctors between countries but not to the detriment of developing populations.
It would be far better to increase the number of Medical School places here and at the same time develop support programmes and, if necessary, tests or examinations which would be applicable to trainees who come to develop their skills and then return to use those skills at home.
I accept that there will continue to be a need for PLAB or a similar test for those who settle permanently but do not let us lose sight of the wider world when dealing with our own administrative problems.
The testing of competence and language skills of EEA graduates is another, albeit related, subject.
M A P Milling OBE
Consultant Plastic Surgeon (retired)
Competing interests: No competing interests
We welcome the initiation of a debate on the support of international medical graduates in the NHS. While adaptations to the testing system may need to be made, as Prof Peile points out in his leader, International Medical Graduates (IMG) doctors make an invaluable contribution to the NHS (1). However, differences at point of entry to the NHS need also to be addressed by targeted support for induction programmes, careers advice and communication skills training. IMG doctors are more likely to be referred for concerns relating to fitness to practise, particularly early on in their UK career (2). In our experience even those doctors who score highly in the PLAB exam or come from the EU need support to ensure a safe transition, to protect both themselves and their patients. Psychiatry and General Practice receive significant numbers of applicants from IMGs however both specialties are highly context specific. Expertise in culturally appropriate communication skills for working with diverse patient groups and colleagues are essential and best acquired through supervised workplace based learning supported by targeted training.
The Professional Support Unit (PSU) hosted by Health Education North West London on behalf of the three London Local Education and Training Boards offers a range of schemes to help IMG doctors transition safely to working in the NHS, ensuring both patient and doctor safety. The Clinical Apprenticeship Placement Scheme for refugee doctors is one such scheme that draws different resources of the PSU together. Post-PLAB refugee doctors are funded in supernumerary FY2 posts, allowing a supervised induction alongside UK trained FY2 doctors. While on the scheme they attend an educational programme targeted at this group which includes communication, cultural awareness, prescribing, team-working, as well as sessions by the BMA ethics team and the GMC on good medical practice. They are also given individual careers advice to ensure realistic career expectations. The scheme has been highly evaluated and showed to greatly enhanced the numbers able to return to work or join training programmes through the usual l routes (3).
Innovative and creative work based induction programmes for IMG doctors are needed to ensure this highly valuable and needed group of doctors are supported, ultimately benefitting the NHS.
1. Peile Selecting an internationally diverse medical workforce BMJ 2014;348:g2696
2. GMC. The state of medical education and practice in the UK report: 2013
3. Ong YL, Trafford P, Paice E and Jackson N. Investing in learning and training refugee doctors. Clinical Teacher, June 2010
Competing interests: No competing interests