Selecting an internationally diverse medical workforce

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.