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Editor's Choice

The plight of the international medical graduate

BMJ 2014; 348 doi: (Published 24 April 2014) Cite this as: BMJ 2014;348:g2894
  1. Tony Delamothe, deputy editor
  1. 1BMJ
  1. tdelamothe{at}

It can’t feel great to be an international medical graduate in Britain right now. Ahead of next month’s European elections, candidates of all political hues are trying to neutralise the appeal of the tiny UK Independence Party by borrowing its anti-immigration rhetoric.

Yet international medical graduates—immigrants—know that they keep the NHS running. Almost 40% of the NHS’s doctors are foreign born; 26% of doctors registered with the General Medical Council qualified outside the European Economic Area. For years the UK has been seemingly content to staff its health service with doctors from countries that in many cases could ill afford to lose them.

They’ve hardly been welcomed with open arms. Once here, achieving professional advancement has been tough. In the game of postgraduate snakes and ladders international medical graduates land on many more snakes than do home grown doctors. Last year Esmail and Roberts calculated the standout statistic: ethnic minority candidates who trained abroad were 14.7 times more likely than white UK candidates to fail the clinical skills component of the Royal College of General Practitioners’ membership exam (doi:10.1136/bmj.f5662). Consternation followed, including an unsuccessful legal challenge by the British Association of Physicians of Indian Origin against the RCGP and the GMC (doi:10.1136/bmj.g2753).

Last week we published two follow-up studies of exam performance commissioned by the GMC. As Ed Peile describes in his linked editorial (doi:10.1136/bmj.g2696), the GMC is considering revising the exams that currently determine an international graduate’s fitness for medical registration in the UK: the Professional and Linguistic Assessments Board (PLAB) parts 1 and 2.

The findings of the two research articles (doi:10.1136/bmj.g2621; doi:10.1136/bmj.g2622) were similar: pass marks for PLAB would have to be set much higher than now if international graduates are to have an equal chance of passing college membership exams. But Peile warns, “If ‘UK equivalent’ pass marks had been applied in years gone by, most of the doctors who have entered UK practice by the PLAB route, and who make such an important contribution to the NHS, would not have been allowed to enter the workforce at that level of performance.”

What to do? Peile thinks the GMC should increase the pass mark for its English language test now, while pass marks for the PLAB exam should be incrementally raised over several years. Phased increases will allow time for a lot more thought, which the recent slew of research suggests is urgently needed. Tom Moberly’s feature brings the history of this knotty problem up to date and should be the starting point for those who have to do the thinking (doi:10.1136/bmj.g2838).

“More research needed” is a bit of a cliché in medical writing, but this week two editorials argue that we should know much more about particular subjects than we do. Iain Chapple reports that longitudinal studies consistently show an association between pre-existing periodontitis and incident atherosclerotic cardiovascular disease (doi:10.1136/bmj.g2645). But we’re still awaiting longitudinal studies showing that interventions reduce “hard” cardiovascular endpoints. Until we have them it’s prudent to remember that association doesn’t necessarily equal causation.

Editorialists mostly associated with Physicians Scientists & Engineers for Healthy Energy take Public Health England to task over its draft report on shale gas extraction (“fracking”) (doi:10.1136/bmj.g2728). Too much of the report stems from starry eyed optimism rather than empirical data, they think. Instead, “the correct conclusion that Public Health England should have drawn is that the public health impacts remain undetermined and that more environmental and public health studies are needed.” Before providing their critique, we could have waited for publication of Public Health England’s final report, but that seems to have been delayed until after next month’s local government elections.


Cite this as: BMJ 2014;348:g2894


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