16 November 2002

career focus
A quick guide to working in the United Kingdom Joanne Constable, Isabel Fish, Claire McKenna s153
Induction courses for international doctors Martha Swierczynski s159
Clinical attachments for overseas doctors Anita Berlin, Sheila Cheeroth s160
Passing the IELTS exam Tony Fitzgerald s162
Preparing for the PLAB test Wai-Ching Leung s163
Postgraduate exams: the MRCP(UK) Jim Benson s164
Tips on . . . Preparing for the MRCP part 1 Sabine Guerry s164
Spruce up your CV and interview skills Sonia Hutton-Taylor s165
Refugee doctors in the United Kingdom Emma Stewart, Sallie Nicholas s166
What to do before you come to the UK and when you first arrive Manoj Kumar s168
The first job Sonali Bapat s169
The staff grade dilemma Sabina Dosani, John Adsett s170
How to enjoy your training as an overseas doctor Kallur Suresh s171
Top tips for getting through the system and having a successful career in the UK Rhona MacDonald s172

THIS WEEK A quick guide to working in the United Kingdom

Joanne Constable, Isabel Fish, and Claire McKenna give a brief sketch of
In the two years that I have been editor of
Career focus, many overseas doctors have
the basics. For more detailed information, please refer to the websites mentioned
shared their experiences with me. I have felt

W
ho exactly is an overseas doctor?
privileged that they have taken me into The definition of an overseas doc-
their confidence but frustrated that I cant tor can differ greatly according to
The Special Case of EEA
do more to help them. That is why we here the angle from which you are approaching doctors
at BMJ Careers have devoted our first ever the question. One of the most important principles of
21 page theme issue to them and their European law is that of free movement.
Introduction Doctors who are citizens of an EEA
special needs at different stages.
Definitions member state and who have qualified in
Negotiating the paperwork and Immigration rules define an overseas doctor an EEA member state have the right to
procedures entailed in coming to the United as: one who regardless of where he/she may live and work in any other country in
Kingdom is a mammoth task, but when you have obtained his/her primary qualification, the EEA. Asking EEA nationals to take a
add all the hoops overseas doctors have to does not have the right of indefinite resi- linguistic test is unlawful as it would be a
jump through to receive limited registration dence or is not settled in the United King- barrier to their right to live and work in
with the GMC, it becomes Herculean. Jo dom, or who does not benefit from another EEA country. It is the
Constable, Isabel Fish, and Claire European Community rights. This defini- responsibility of the employer to make
McKenna (p s153) give a guide through tion also includes doctors who may have sure that the doctor is proficient in
received a primary medical qualification written and spoken English.
this complicated process and explain the
from a United Kingdom university but who
different training structures for hospital do not have the right of indefinite residence.
doctors and GPs in the United Kingdom. The General Medical Council defines an ment of Health medical and workforce cen-
In the next section (pp s159-65) we overseas doctor as: Someone who has sus found that 24% of doctors working in the
concentrate in more detail on how to help obtained their basic medical qualification NHS were not from the UK.1
overseas doctors along the path to obtaining outside of the UK. The same report stated: Clearly, substan-
their first job. This includes how induction tial numbers of overseas doctors will con-
courses and clinical attachments can help; Why would an overseas doctor want to come tinue to be needed in order to meet the
tips on how to pass the IELTS, PLAB, and and work in the United Kingdom? expected demand for healthcare.
Overseas doctors are not a homogeneous
postgraduate exams (using the MRCP(UK)
group. Some doctors may be refugees or
as an example); and some advice on how to asylum seekers who are forced to flee their The next step
improve CVs and interview skills. home countries. Others may be enticed by After sorting out whether you are an over-
In the last section (pp s166-71), overseas better living and working conditions or bet- seas doctor and why you want to come to the
doctors share their experiences and give ter pay than they receive in their home coun- UK, and after arranging immigration and
some specific advice to other overseas try. Some doctors may simply want to come visa requirements, the hard work begins.
doctors on what to do when they first arrive to the UK to gain skills which are not avail- Your main aim before you can begin any
able in their home country and bring what clinical work or write prescriptions is to get
in the United Kingdom, how to get their
they learn back to their patients at home. Still limited registration with the General Medical
first job, and how to make the most of their
others may come to the UK on a short term Council so that you can be placed on the UK
training. To finish with, I have Medical Register.
basis to teach new skills to doctors in the UK.
amalgamated the top tips overseas doctors This article is a basic guide and does not
have sent to me to help other overseas Why does the UK government want overseas cover everything in detail. You can obtain a
doctors through the system. doctors? comprehensive guide for doctors wishing to
We are reproducing this issue into a free The new European Working Time Directive work in the UK from the BMAs Inter-
booklet which will be available at our which has been implemented in the UK is national Department (internationalinfo@
careers fair (29-30 November). Yet another expected to create increasing staffing pres- bma.org.uk).
good reason to come. sures among doctors, and the NHS is likely
to become increasingly dependent on the Immigration
Rhona MacDonald editor of Career focus services of overseas doctors. The UK Depart- Overseas doctors coming to the UK must
careerfocus@bmj.com ment of Health has had a recent overseas satisfy UK immigration requirements. Immi-
tel: + 44 (0)20 7387 4499 recruitment drive. The most recent Depart- gration law is very complex and doctors

BMJ CAREERS 16 NOVEMBER 2002 s153

career focus

should seek detailed advice from the Home project collects details on the number of
Office (www.ind.homeoffice.gov.uk). If you refugee doctors in the UK, their location, and
are outside the UK you should contact your the stage of their career and registration
local British embassy or high commission for process. For more information and a copy of
further information. an information book for refugee doctors
Doctors who are citizens of the countries please contact the BMA International
in the European Economic Area (EEA) or of Department. For further information about
Switzerland are entitled to enter the UK immigration requirements within general
freely and work here. practice refer to p s158.
Doctors from beyond the EEA may have
rights to live and work in the UKfor exam- GMC registration
Doctors who wish to practise medicine in the
ple, if they are the spouse of an EEA national
UK need to be registered with the General
or workpermit holder or because they have
Medical Council (fig 1).
Commonwealth ancestry. Doctors who think
There are four different types of regis-
that they may have such rights should seek
tration with the GMC: provisional, limited,
advice from the Home Office or the British
full, and specialist.
representative overseas.
Provisional registration
Postgraduate permit-free training status Allows doctors who have qualified in the UK
Doctors wishing to do postgraduate training and EEA (who are also EEA nationals) and
in UK hospitals or community health serv- those qualified in Australia, Hong Kong,

LIANE PAYNE
ices must have permit-free postgraduate New Zealand, Singapore, South Africa, and
training status, which means that they are the West Indies, to work in preregistration
allowed to work without a work permit. To house officer posts which are approved for
qualify for this, the doctor must have GMC the purpose of preregistration service.
registration and show that he or she intends
to work in a training post within the NHS. Limited registration Specialist registration
Full details can be found on the Home Office Allows overseas qualified doctors, who hold Allows doctors to take up a substantive or
website. an acceptable qualification (included in the honorary consultant post in the NHS. No
World Health Organizations list of Medical doctor can take up these appointments
Work permits Schools) to practise in supervised NHS train- unless they are on the specialist register.
Doctors working in hospital career grade ing posts (preregistration house officer, sen-
posts (non-training grades) as consultants or ior house officer, specialist registrar) which
as salaried or locum GPs will require a work are educationally approved. It is also granted Temporary full registration
permit. Employers must apply for the permit for locum posts at these grades. (Note that There are also some special cases where
from Work Permits UK. A usual requirement although the post you may take is at JHO overseas qualified doctors can be granted
is that no suitably qualified EEA national is level you need to be at an SHO standard to temporary full registration. This is for doc-
available to do the job. A work permit is pass the PLAB exam needed to get GMC tors who are coming to the UK to provide a
specific to a particular post and cannot be registration.) temporary specialist service (for example,
transferred should you obtain another job demonstrating a particular technique that is
before it expires. Full registration
Allows doctors to practise in unsupervised not available in the UK) for a short period of
Asylum seekers and refugees medical practice in any post in the NHS and time. All other overseas doctors have to
The BMA and the Refugee Council jointly in private practice. This type of registration is apply for limited registration.
run the refugee doctors database. The needed to work as a general practitioner.
How long does limited registration last?
Limited registration is granted for periods
Obtain a primary medical qualification on a list published by the World
Health Organisation (www.who.int/health-services-delivery/med_schools/) totalling no more than five years. Overseas
doctors who have just passed their PLAB
Pass the International English Language Testing System (IELTS) with a satisfactory score
examination will normally be given one year
and one week. Registration expires at mid-
You may want to do a clinical attachment night on the last day of registration shown on
your certificate of limited registration. You
Pass the GMCs Professional and Linguistic Assessment Board Test (PLAB), a two part test assessing can apply to renew your registration up to
basic medical competence and ability to communicate in English for work at senior house officer level three months before the date on which you
In some instances, you may be exempt from it
need further limited registration.

Find a job in a supervised NHS training post which is educationally approved

How do I renew my limited registration?
Before further limited registration can be
Complete the application form for limited registration and send to the GMC with original documentation granted, the GMC needs to be satisfied that a
confirming you have passed PLAB and IELTs and the registration fee
doctors performance complies with the
standards of competence, care, and conduct
Limited registration described in the GMCs publication Good
Lasts for 1 to 5 years (usually 18 months initially for overseas doctors). There is a yearly fee for staying on the register,
and registration may need to be renewed every year. Can work in posts up to the level of specialist registrar
Medical Practice. The assessment of this is
carried out by the doctors supervising
consultants, using a GMC report form.
You may proceed to full registration Apply for a national training You may be able to go direct to a Application forms, report forms, and fact
(normally you need to have 24 number to get on specialist specialist post if deemed eligible sheets can be downloaded from the GMC
months experience) registrar training post by specialist training authority website (www.gmc-uk.org). You should aim
to submit the application form for renewal of
To train as a General Practitioner, at the time of writing, you need to have full registration
registration as early as possible. Make sure
you have all the evidence and fees required,
Fig 1 Overview of process to obtain limited registration with GMC or this may delay your application.

s154 BMJ CAREERS 16 NOVEMBER 2002

 career focus

How do I progress to full registration? org.uk. IELTS preparation courses run in

You normally need at least 12 months many colleges and universities across the UK
experience at SHO or specialist registrar and in other countries. For more information
Special note
with limited registration to apply for full contact your local testing centre (found at Passing the PLAB test does not
registration. (See the GMCs website for a most universities and some colleges). guarantee a job, and you need a job to
factsheet giving all the criteria for full regis- get limited registration with the GMC.
tration.) Again, you need to supply an appli- How much does IELTS cost?
cation form (available on GMCs website), a IELTS currently costs 73. Payment should
consultant report from your supervising accompany the completed application form. Part 2 of the test can only be taken in the
consultants, and a registration fee. UK.
How long does IELTS last, and how often can
What are the costs involved in registration? I do it?
The IELTS test report form is valid for two How much will taking the PLAB test cost?
You will need to pay a fee every time you
years. Any doctor who has not obtained Current fees are 145 for part 1 and 430 for
apply for registration. The amount depends
registration within this time, or in the case of part 2 (but see the website for more up to
on which type of registration you are apply-
PLAB test candidates has not passed part 1 date information). Refugee doctors living in
ing for and whether it is an initial registration
of the PLAB test within this time, will need to the UK do not have to pay the fee for Part 1
or a renewal. For information on exact
take the IELTS again. There is no limit on the on their first two attempts, but there is no
fees see www.gmc-uk.org/register/fees.htm.
number of times a person may sit the exam. exemption from part 2. Eligible doctors need
Unfortunately, there are no exemptions
However, a candidate is not allowed to sit the to send the GMC a copy of a letter from the
from payment of fees for doctors who may
exam within three months of a previous Home Office confirming their refugee status.
not be able to pay.
attempt.
Explaining IELTS For links to some excellent sites with How many times can I take the PLAB test?
One of the registration requirements for all information on IELTS, practice papers, and There is no limit on the number of times you
doctors who qualify outside of the European tips for IELTS candidates, see www.british can take part 1 of the PLAB test. You may
Economic Area is that they must demon- council.gr/english/materials3_ielts.htm. have four attempts at Part 2, which must be
strate that they have the necessary knowl- within two years of passing Part 1. If you fail
edge of English by obtaining a satisfactory Explaining PLAB the PLAB test on the fourth attempt you
score in the IELTS (the International English The PLAB (Professional Linguistics Assess- must retake the IELTS and Part 1 again.
Language Testing System). ment Board) examination is a difficult exam-
ination said to be somewhere between finals
and postgraduate examinations in level of How do I apply for the test?
Facts about IELTS You must fulfil all the preconditions and
+ IELTS is a test of the skills that are difficulty.
complete and return an application form
needed for study in an academic context
What does the PLAB test involve? (which you can down load from www.gmc-
in the UK
There are two parts to the PLAB test: uk.org/register/plab.htm) with the appro-
+ The test has four separate components:
+ Part 1 consists of a three hour extended priate fee.
listening, speaking, reading, and writing;
matching question examination which
each is scored individually and an overall
emphasises clinical management but Exemption from PLAB
score awarded
also includes science as applied to
+ It is not a pass/fail exam: the test is If you are a doctor on the Overseas Doctors
clinical problems. Training Scheme (ODTS), or are sponsored
banded from 1 to 9, with 1 indicating a
+ Part 2 is an Objective Structured Clinical by the British Council, you will be exempt
very basic knowledge of English and 9
Examination (OSCE) with 14 stations. from PLAB (see below).
indicating language skills at native
The aim of the OSCE is to test
speaker level
candidates clinical and communication
+ The GMC asks for an overall score of Sponsorship by the Medical Royal
skills in a number of controlled
7.0, with a score of at least 7.0 in the Colleges
situations. The Overseas Doctors Training Scheme
speaking component and a score of no
less than 6.0 in the other three (ODTS) is a scheme run jointly by the
Requirements for taking the PLAB test
components. To be exempt from the Department of Health and the Medical
Candidates must have:
PLAB tests you must gain at least 7.0 in Royal Collegestherefore it is also referred
+ A primary medical qualification
all four sections of the IELTS test. to as a double-sponsorship scheme. How-
acceptable for limited registration (see
ever, some royal colleges no longer operate
WHO list http://www.who.int/
How can I apply for IELTS? the double sponsorship scheme and sponsor
health-services-delivery/med_schools)
Candidates can sit the examination in centres overseas doctors independently; contact the
+ Taken and obtained an acceptable score
all round the world. For information on your relevant Royal College for the latest infor-
in the IELTS. The GMC currently
nearest IELTS testing centre go to www.ielts. mation.
requires a higher IELTS score for
doctors who are exempt from the PLAB.
+ A valid IELTS report form dated not
more than two years before each
attempt.
Although newly qualified doctors can apply
for the PLAB, you need to be competent to
standard of an SHO to pass (even though
you will only be allowed to work as a prereg-
istration house officer), so clinical experience
is advisable before applying.

Where can I take the test?

Part 1 of the test can currently be taken in the
UK, Egypt, India, Nigeria, Pakistan, Bangla-
desh, Sri Lanka, and Bulgaria. A list of spe-
LIANE PAYNE

LIANE PAYNE

cific test dates and centres can be obtained

from the GMCs website.

BMJ CAREERS 16 NOVEMBER 2002 s155

career focus

Why?
Clinical attachments can be very useful, espe-
What are the Medical Royal Colleges? cially before the second (clinical) part of the
+ These are colleges which represent the main specialties (including general practice) PLAB examination. It is probably best to do
within medicine in the UK. Specialists in a particular area become a member of their an attachment after passing the IELTS exam-
particular royal college, which represents their needs ination so that you can get the most out of it
+ The colleges conduct postgraduate medical examinations, training, education, and and get a good reference.
research in medicine and advise the government, the public, and the medical Clinical attachments may help to give you
profession on health and medical matters an understanding of how the NHS works
+ Presidents of the medical royal colleges become members of the Specialist Training and how medicine is practised in the UK.
Authority of the Medical Royal Colleges, which issues certificates for completion of They might also help you to brush up on
specialist training in the UK (CCST) and approves doctors for entry to the specialist clinical skills, which may be rusty if you have
register held by the GMC been out of work for a while, and give you
+ There are 18 royal colleges in the United Kingdom, together with the Irish colleges some insight into the knowledge base that is
and the Faculty of Dental Surgery; they are represented at the Academy of Medical required of UK doctors.
Royal Colleges (www.aomrc.org.uk/index3.html) A clinical attachment might also help you
overcome cultural differences that you will
face in the UK, as well as familiarise you with
The scheme allows very competent over- VAT for first arranging registration and local accents and peculiar phrases you might
seas doctors to be exempt from the PLAB 400 plus VAT for renewal. not be used to. There may also be diseases
examination, so that they can continue their + A minority of the doctors who the and investigations that are common in the
specialist training in the UK before returning British Council sponsors hold UK but you may not be so familiar with.
home. The scheme is not designed for over- scholarships. These doctors can be An attachment may be the only way an
seas doctors to remain in the UK after com- placed in honorary trust fellowship overseas doctor can get a reference from a
pleting their specialist training. positions. UK consultant, which could prove very
Requirements for sponsorship vary, so you + The British Council is reluctant to helpful when it comes to looking for jobs.
would need to contact the individual colleges publicise its scheme as it is growing by
to find out details (go to www.aomrc.org.uk/ 30% a year by word of mouth and is How?
netscapepages/links/collegelinks.html for already oversubscribed it says the There is no central body which arranges
the college relevant to you). administrative arrangements will not clinical attachments. The best way to find an
However, all colleges will require a score cope with a vastly increased demand. attachment is to write to individual hospi-
of at least 7.0 in all four bands of the IELTS + So be aware of the limitations, but to find tals, enclosing a CV. Personal contacts can
test, at least two years experience in the spe- out more information and get a pack also be useful. The BMA has published
cialty in which they wish to practise, and a detailing criteria call the National Advice guidelines on clinical attachments, which
primary medical qualification acceptable to Centre for Postgraduate Medical are available on www.bma.org.uk/ap.nsf/
the GMC for Limited Registration. However, Education (NACPME) on 01609577218 Content/Clinicalattachmentguidelines-
there are some criteria for excluding or go to www.britishcouncil.org/health/ introduction (and see article on p s160).
applicants from the scheme (see box) nacpme/
Finding a job (to get Limited Registration)
What are clinical attachments and why To recap, in order to get limited registration
Applicants to the ODTS will might you do them? with the GMC you need to find a job in a
be excluded if they: supervised NHS training post. Before that,
What? you need to have passed IELTS and PLAB
+ Have previously failed the PLAB test A clinical attachment is a work placement exams (or be exempt from the PLAB).
+ Do not hold Part 1 of the relevant carried out at a hospital where you are able Most jobs in the NHS are advertised in
royal colleges examination (clarify to shadow a doctor and find out about the BMJ careers (go to www.bmjcareers.com). You
requirements with appropriate royal work they do and how the hospital works. have to apply to the employer directly and
college) You will not be paid for a clinical attachment; send a CV (see p s165) or an application
+ Qualified in or are nationals of an it is purely for your own benefit. You will form (check the job advertisement to see if
EEA country, or a country with normally have a named supervisor who is an application form is required). Employers
enforceable EC rights responsible for you. Clinical attachments then form a short list of all the applicants
+ Are already working in or are normally last between two and four months. and invite these applicants for an interview.
resident in the UK or another
member state of the European Union
Undergraduate student - 5/6 years

Many of the colleges will not accept appli- Preregistration house officer - 1 year
cations directly from candidatesonly appro-
priate sponsors may apply on their behalf
but some do, so check it out (see www. Senior house officer Senior house officer
britishcouncil.org/health/nacpme/odts.htm Basic specialist training 3 or 4 years working in 2 years in a variety of specialties. May be on a
for more information). various specialties. designated general practice training scheme or 'DIY'
Usually sit the relevant royal college exam
British Council sponsorship and trust
fellowships GP registrar
+ The British Council also sponsors Specialist registrar 1 year
4-6 years. Higher specialist training
overseas doctors, usually with at least
three years experience in their chosen General Practitioner
specialty, to come to the UK for part of Specialist doctor Will obtain a certificate of prescribed or equivalent
their postgraduate training, exempting Holds CCST. Is named on GMCs specialist register experience from the Joint Committee on Post graduate
May be appointed as a consultant Training for General Practice. May do examination of
them from the PLAB. royal college of General Practitioners
+ There are country-specific criteria for
sponsorship and there are some
management fees involved: 700 plus Fig 2 Overview of a doctors career path in the UK

s156 BMJ CAREERS 16 NOVEMBER 2002

 career focus

Senior House Officer training Specialist Training Authority

(STA)
Type I specialist Type II specialist Non- consultant Locum appointment Locum appointment The STA (along with the Joint
registrar training registrar training career grade for training (LAT) for service (LAS) Committee for Postgraduate Training
General Practice, JCPTGP) currently
Specialist doctor approves curriculums for specialist
training and judges whether individual
doctors have reached the standard set
Fig 3 Career options after SHO training
for them by satisfactory completion of
You need to be shortlisted and pass the inter- training. One of the STAs roles is to
The specialist registration process
view to get the job. However, the process of By law in the UK, doctors must have their approve or reject applications for
securing a job is fraught with difficulties. names on the GMCs Specialist Register specialist registration from doctors with
before taking up a fixed term NHS consult- overseas qualifications.
Higher specialist training ant post, but this does not apply to locum For overseas doctors, the medical royal
The process of obtaining higher training NHS consultant posts. colleges act as agents of the STA and
and obtaining registration as a specialist Although it is a legal requirement to be on undertake an initial assessment of an
(fig 2) is rather bewildering, even for those of the Specialist Register, it is not a legal application, seek references and further
us living in the UK. There are many alterna- requirement to be on the register in the exact documentary evidence, and submit a
tive career paths which do not lead to regis- specialty in which a doctor may wish to recommendation to the STA. Once the
tration as a specialist but allow you to work at practisethe employer decides if the doctor STA receives the recommendation with
a higher level not in a specialist training has the particular skills and expertise the applicants details from the relevant
programme. Hopefully figure 3 will help required. Being listed on the specialist regis- college or faculty, it will make a decision
make sense of it all. ter does not automatically mean you will be on each application on whether a
For specialist registrar training, appoint- shortlisted for or appointed to a consultant Certificate of Completion of Specialist
ment is by open competition to the relevant post. Training (CCST) should be awarded.
deanery. The minimum entry requirements It is proposed that the Medical
are two years in the SHO grade plus the first Other work options Education Standards Board (MESB) will
part of a postgraduate qualification (for Locum appointments soon replace the STA (see www.doh.
example, part 1 of the MRCOG exam.) Those All doctors, with or without right of indefinite gov.uk/medicaltrainingintheuk/
who are successful in getting a specialist reg- residence or settled status and irrespective of mesb-consultation/)
istrar post will get a National Training their training status, are also eligible for
Number (NTN). Unfortunately the number of locum appointments for training (LAT),
NTNs is limited. which offer opportunities for training similar regarding their appointment, no formal edu-
to the type I training programme, and locum cational opportunities, and little possibility
appointments for service (LAS), which are of career progression.
Special note: Catch 22 not training appointments. NCCG posts are often filled by overseas
To get limited registration with the doctors who have come to the UK for training
GMC, you need to have found a job. It is Non-consultant career grade doctors
but have failed to find training posts or have
difficult to find a job if you dont already The term non-consultant career grade doc-
been unsuccessful in passing examinations.
have limited registration. tor (NCCG) is an umbrella term for associate
specialists, clinical assistants, hospital practi- Staff Grade
tioners, and staff grade or trust grade doc- (SG) was introduced to make up the shortfall
tors. There is much debate in the UK about of doctors in the middle grades following
Type I specialist registrar training the limitations in the number of Specialist
the non-consultant career grade. Some doc-
After entry into type I specialist registrar Registrar posts in order to find a way of
tors find job satisfaction in these posts, which
training, there are annual assessments called providing essential support to consultants
have the advantage of extensive clinical con-
RITAs (Record of In-Training Assessment), in the acute specialities without training
tact but avoid the bureaucracy and the
which you need to receive a satisfactory doctors for non-existent posts.1
administrative and management responsi-
grade in. After you have completed all of
bilities that consultants have. However, often Associate Specialists
them, this will lead to the award of a Certifi-
NCCGs are appointed by trusts to fill gaps in (AS)this is a senior grade usually filled by
cate of Completion of Specialist Training
services when doctors in training are not doctors who have, for one reason or
(CCST) and entry to the Specialist Register
available. There are no rules on safeguards another, chosen not to complete higher
held by the GMC. The Specialist Training
Authority (STA), supported by a recommen-
dation from the relevant royal college or
faculty, decides whether or not an individual
Difficulties in job hunting
doctor has met the standard required for a + The UK does have a shortage of doctorsbut only in certain parts of the country and
specified training programme, to merit the in certain specialties. The most popular specialties are the surgical subspecialties, so it
award of a CCST. may be difficult to get a job in one of these
+ In the job market, you will be competing against doctors from the UK and there is
Type II specialist registrar training strong competition for training posts. It may be wise to check out the job
Overseas doctors can also work as type II opportunities in the specialty you are interested in before coming to the UK
specialist registrars on fixed term training + Even though passing the PLAB exam means that you are competent to work up to a
(FTT) appointments. Type II training pro- level of senior house officer, you may have to take a preregistration house officer post
grammes are specifically designed to meet if you cant get work as an SHO
the needs of the individual overseas doctor, + If you receive the results from your PLAB exam after the traditional times for the
but they do not lead to a CCST. Doctors are changeover of jobs (August and February) it may be too late to apply for these posts.
able to transfer from a type II to a type I post You may have a wait of several months before getting a post. During this time you
if they are successful in open competition might want to keep your skills up to date by restarting your clinical attachment
(where they will be awarded a visiting train- (although you are not allowed to prescribe until you have GMC registration).
ing number, VTN).

BMJ CAREERS 16 NOVEMBER 2002 s157

career focus

+ On completion of the training

programme a doctor is eligible to apply
Some frequently asked questions for a Certificate of Prescribed
What if I have specialist qualifications awarded outside the UK? Experience from the competent
You can apply to the Specialist Training Authority (STA) for entry to the Specialist authority for GP training. This is
Register. You will have to convince the STA that your qualification is equivalent to a UK currently the JCPTGP, but its functions
CCST or that you have the level of knowledge and skills required by a consultant in are soon to be transferred to the
the UK. Postgraduate Medical Education and
How do I apply for specialist registration? Training Board (see www.doh.gov.uk/
Contact the college or faculty relevant to you; they will provide you with an information medicaltrainingintheuk/gptraining.htm
pack with details of the criteria for overseas applicants and an application form. If you for more details)
think you are eligible to apply, send off the application form to the college or faculty,
with all the documentation that is requested. The training work experience permit
An overseas doctor who wishes to enter a GP
How long does it take to process an application? registrar post must obtain a training work
Normally about three months, if referees respond promptly. When the assessment experience (TWES) permit (see www.work
process is complete, the college or faculty will forward a recommendation with details of permit.com/uk/twes.htmtalk and www.jcptgp.
your overseas training and specialist qualifications to the STA. If your application is org.uk/certification/overseas_doctors.asp
successful, the STA will send a form for you to complete, to apply to the GMC for entry and contact your local postgraduate deanery
to the specialist register. for advice).
Holders of TWES permits are normally
required to leave the UK at the end of the
medical training or, having completed Training as a GP period for which the permit was granted;
higher specialist training, have not taken up Currently, you need full registration to work however, the Home Office has agreed that
a consultant appointment. They must have or train as a general practitioner in the UK. those undertaking GP registrar training on
completed 10 years medical work since You can either make up your own training TWES permits will not be subject to normal
registration. scheme by applying for individual accredited TWES restrictions.
Trust Doctors posts or apply for a place on a vocational
Are unapproved non-training posts training scheme (VTS), which will organise
invented by trusts to fill service gaps. Often these posts for you. VTSs are organised by Special note
they have no national terms and conditions local directors of postgraduate general prac- All overseas doctors who are successful
of service. tice education. There is no defined order in in applying to a deanery for a general
which posts should be completed. practice training programme will be
The training path for a GP in the UK is to: funded by the NHS for the GP registrar
+ Work as an SHO for two years in a element of their training programme.
Useful information hospital rotating round hospital
Most of this information is scattered specialist posts that have been accredited
through out this article but it might help for GP training. You can do this with Once you have finished training as a GP
you if it is in list form. Limited Registration with the GMC. The registrar, two options are open to you. You can
BMA International Department accreditation process is overseen by the apply for salaried GP posts, for which you will
Tel : +44 (0)20 7383 6793/6133 Joint Committee on Postgraduate need a work permit, or you can become a GP
internationalinfo@bma.org.uk Training for General Practice and the principal and apply to remain in the UK
www.bma.org.uk/international Royal College of General Practitioners. through the Highly Skilled Migrant Pro-
GMC gramme (HSMP) (see www.workpermit.com/
Registration enquiries: uk/highly_skilled_migrant_program.htm
Tel: +44 (0)20 7915 3635 or email Special note: Service Grade and www.workpermit.com).
regservices@gmc-uk.org You can also apply to the HSMP if you are
Some publications you may read use the already a fully trained GP in your own coun-
www.gmc-uk.org term Service Gradeit is basically made try. However, you must obtain a Certificate of
National Advice Centre for up. Sometimes it is used as an umbrella Equivalent Experience from the JCPTGP
Postgraduate Medical Education term to encompass NCCGs, consultants, before you can take up a post.
(NACPME) and general practitioners; other times it
Tel: +44 (0)161 957 7218 is used to mean the same as a NCCG Joanne Constable
www.britishcouncil.org/health/nacpme post. jconstable@bma.org.uk
Medical Royal Colleges
For a list see www.aomrc.org.uk/pages/ Isabel Fish
links/collegelinks.html + Work in an approved general practice International department, BMA, London
partnership under the guidance and Ifish@bma.org.uk
Regional Postgraduate Medical
Deaneries instruction of an approved GP trainer.
Claire McKenna Former BMJ Clegg scholar and
For a list see www.copmed.org.uk/ This is called the GP registrar post, and
third year medical student
deaneries you need Full Registration to enter it. Queens University, Belfast
+ During training, doctors undergo an comckenna@hotmail.com
Specialist Training Authority (STA)
assessment (Summative Assessment)
Tel: +44 (0)20 7935 8586 Thanks to Chris Finlan from the BMAs Junior
process to test their competency (see
www.sta-mrc.org.uk Doctors Committee and John Maingay from the
www.rcgp.org.uk/rcgp/information/ BMAs General Practice Committee for their help
Joint Committee for Training in publications/information/rcf0009/ in checking the factual content of this article.
General Practice (JCTGP) Rcf0009c.asp)
Tel: +44 (0)20 7581 3232 + Towards the end of their training many
Further reading
enquiry@jcptgp.org.uk Guide for doctors new to the UK. London:BMA,
doctors elect to take the Royal College of 2002. (Available free from the BMA International
www.jctgp.org.uk General Practitioners membership Department.)
Home Office examination: the MRCGP. But this is not
1 Department of Health and Social Security. Hospital
www.ind.homeoffice.gov.uk a necessary requirement for completion medical staffing: achieving a balance. London: DHSS,
of GP training. 1986.

s158 BMJ CAREERS 16 NOVEMBER 2002

 career focus

Induction courses for international doctors Box 2: Some commonly used

Martha Swierczynski explains who is eligible and how the courses can help abbreviations
+ DOA: dead on arrival

W
hen doctors from overseas begin Some deaneries run separate courses for + OD: overdose
their career in the United King- doctors looking for a post and doctors who + BIBA: brought in by ambulance
dom, they often feel a little lost. have gained a post. Others run induction + BID: brought in dead
Cultural and technical differences can leave courses that cover issues needed by both + BO: body odour or bowels open
international doctors (doctors who have groups. The courses are funded by the + SIDS: sudden infant death syndrome
trained in the United Kingdom) feeling Department of Health and are free for doc- + SAE: stamped addressed envelope
alienated in the NHS. And it is not only tors and their employers. Travel and accom- + TTA: to take away
doctors from developing countries who find modation expenses are also covered. The + TTO: to take out
the NHS difficult to fit into. Doctors from courses last two to five days (depending on + TTH: to take home
other states in the European Union experi- the deanery) and provide advice and guid-
ence similar problems. However, the differ- ance on a wide range of topics relevant to
ences between medical practice in their international doctors of all levels entering English terms for diseases and procedures,
home country and medical practice in Brit- the NHS. Deaneries are advised to make the they have rarely encountered the abbrevia-
ain can easily be overcome with a little guid- courses as accessible as possible. If a doctor is tions that are commonly used in hospitals
ance and advice. This is where induction already in post he or she should be allowed
and surgeries. A lesson in abbreviations can
courses come in. to use some study leave to attend the course.
make a huge difference to their integration
What is covered? into the NHS, and a list of common abbre-
Eligibility for induction courses All doctors are given an induction at trust viations handed out at an induction course
Induction courses for international doctors level when they join the NHS, but this is can make their first few weeks in post a lot
have been run regularly by postgraduate usually the same for all doctors, regardless of easier (see box 2).
deaneries throughout England for the past their origin. This induction focuses mainly Many of the induction courses include a
two years. Doctors from all over the United on introducing a doctor to the structures and
Kingdom are eligible to attend and can session on breaking bad news, using role
procedures in that particular trust. The dean- play. There are massive cultural differences
attend whichever course is most convenient eries courses are designed to supplement
for them. in rules regarding body and eye contact. If
trusts courses and have additional topics
These courses are open to all non-UK these differences are not explored, a doctor
that are specific to international doctors
medical graduates from both inside and out- risks offending a patient or upsetting them
(box 1). Two of the most important areas
side the European Economic Area (all the further.
covered are communication skills and aca-
countries of the European Union plus Ice- demic development.
land, Liechtenstein, and Norway). Academic development
Induction courses were originally set up Some doctors arrive in Britain believing that
for international doctors starting their first they are entering a training post, only to find
post in Britain to introduce them to the cul- that the post they applied for and accepted is
ture of the NHS. However, in 2002, the a trust grade post and doesnt provide the
induction courses were opened up to all training opportunities they expected. They
international doctors who were eligible for can gain a lot from the short description of
GMC registration, even if they were still look- UK medical training that is given on the
ing for a post. It had become clear that one of induction course, which outlines the training
the main obstacles for international doctors system from preregistration house officer
when applying for jobs in the NHS is famil- level to consultant. Also basic CV writing and
iarisation with the system, so job seeking interview skills are shown and practised, and
LIANE PAYNE

doctors could also benefit from induction in the doctors have a chance to get honest feed-
the NHS culture. back about their performance.

And finally . . .
Box 1: Topics covered Communication skills The government strongly encourages all
Many international doctors say that one of
+ The NHS structure international doctors ready for work in the
the first hurdles is understanding the lan-
+ Living in the United Kingdom United Kingdom to participate in an induc-
guage. All doctors who start work in the NHS
(banking, schools, housing, transport, tion course. Employers taking on doctors
will have had to satisfy their employer that
and sports) from abroad should ensure that they send
they have good communication skills, as rec-
+ Colloquial English their doctors on an induction course as soon
ommended by government guidance. 1 Most
+ Medical abbreviations as possible.
doctors from outside the European Eco-
+ Communication skills
nomic Area also have to pass the Inter-
+ Immigration regulations Martha Swierczynski business manager
national English Language Testing Service
+ Informed consent Learning and Personal Development, Human
(IELTS) exam before being eligible for regis- Resources Directorate, Department of Health, Leeds
+ Death certification
tration with the General Medical Council. Martha.Swierczynski@doh.gsi.gov.uk
+ Prescribing and the law
But even though international doctors work-
+ Postgraduate medical education and I thank Anita Gayen at the London Deanery for
ing in the NHS have proved adequate Eng-
training her contributions.
lish to practise safely, this does not mean that
+ Examinations and study leave
they are able to understand the broad
+ Junior doctors hours Further information
accents and colloquialisms that they encoun- NHS Professionals (tel 0845 1203167; fax
+ How to get your next job
ter in parts of Britain. They need introducing 0114 2758008; email lyndsay.towers@wymas.
+ Permit free training plus immigration
to the different uses of the English language nhsprofessionals.nhs.uk)
+ Drugs and their doses
and some of the slang they may hear.
+ Employment law 1 Employment of European Economic Area (EEA)
The language of the health service is full
+ Risk management nationalsensuring language competency. London:
of abbreviations. Although most inter-
+ Clinical governance Department of Health, 1999. (Health Service Circular
national doctors are aware of the proper 1999/137.)

BMJ CAREERS 16 NOVEMBER 2002 s159

career focus

part to play. Human resources staff and man-

Clinical attachments for overseas doctors agers can help with inquiries about clinical
attachments by providing written infor-
Anita Berlin and Sheila Cheeroth discuss what everyone participating in mation and application forms.
clinical attachments needs to consider, and Ignasi Agell and Sajid Siddiqi They should draw up criteria for accept-
ing and placing overseas doctors with clini-
share their personal experiences cians. Although attached doctors are unpaid

T
he principal purposes of clinical + Invest in future staff who are likely to stay and therefore require no formal contract,
attachments are to provide overseas on permanently (especially refugees and human resources staff have an important
doctors with experience of NHS health people with permanent residence rights). role in setting ground rules for attachments
care and an opportunity to gain a reference and ensuring that some form of learning
from a clinician based in the United King- Organisation contract is agreed between the attached
dom. Overseas doctors gain confidence It is easy to provide a bad clinical attachment doctors and their clinical supervisors.
through clinical attachments and are more one that is ill timed, unstructured, pays no
likely to pass the Professional Linguistic heed to the learning needs of the individual Location, timing, and specialty
Assessments Board (PLAB) exam and secure overseas doctor, and provides insufficient con- Location
their first post. tact with patient care and clinician feedback. Overseas doctors are concentrated in large
The attachment should provide first hand Most attachments will be part time; they urban centres in the United Kingdom (prob-
experience of health care in the United King- should last a minimum of two months and ably at least 60% in London, followed by
dom. The supervisor should be able to assess probably a maximum of four months. Birmingham, Manchester, and Glasgow),
whether the attached doctor is ready for lim- and they are likely to be familiar with the
Who needs to do what?
ited registrationto work as a senior house names of the bigger teaching hospitals.
Overseas doctors need to be sure that they
officerand provide appropriate construc- According to anecdotal evidence, however,
are doing the clinical attachment in the right
tive feedback throughout the attachment.1 district general hospitals have much to offer.
specialty and location and at the right time
They are less crowded with students and
(see checklist in box).
Why clinical attachments? provide a broad exposure to health care,
NHS providers need to be sure that they
which is better preparation for the PLAB
are adequately prepared to assess and
For overseas doctors, clinical attachments: examination. Overseas doctors may be
respond to the attached doctors needs and
+ Provide learning in the NHS and the understandably reluctant to move to an
that they have something to offer, such as
United Kingdoms medical, legal, and unknown area, but district general hospitals
induction, clinical opportunity, and supervi-
cultural traditions with a track record of providing clinical
sion. They also need to understand the legal
+ Refresh clinical knowledge and skills attachments sometimes also provide tempo-
and welfare issues affecting the attached doc-
+ Are the only way in which qualified rary accommodation (particularly in areas
tor and monitor the quality of the attachment.
overseas doctors (especially refugees) away from London and the south eastin
Traditionally, clinical attachments have
can get a reference from a British some cases, family members may also be
been arranged informally, directly with indi-
consultant, which is very helpful for housed).
vidual volunteer hospital consultants.
getting a job. Increasingly, however, hospital trusts and
Specialty
primary care providers are looking at ways of
People have a natural tendency to seek an
For NHS providers, clinical attachments: providing more structured and formal
attachment in the specialty of their initial
+ Are an investment in a medical opportunities for individuals and small
training or greatest experience. The volun-
professional who is likely to join the groups of overseas doctors, particularly refu-
tary register of refugee doctors in the United
workforce gee doctors.
Kingdom established recently by the
+ Are an opportunity to attract new For a clinical attachment to be worth
BMA/Refugee Council shows that a huge
doctors into trusts and areas outside the while, human resources departments, man-
range of prior experience exists.
traditional teaching hospital circuit agers, and participating clinicians all have a
Many people on the register have experi-
ence in specialties that are overcrowded in
Checklist for overseas doctors seeking a clinical attachment the United Kingdom (in particular, obstetrics
and general surgery). Careful thought and
+ Have I got my CV in good shape? career guidance may help an overseas doctor
+ Have I contacted all the possible local providers, hospital personnel departments, decide whether to pursue his or her original
postgraduate deaneries, primary care trusts? specialty or to redirect energies to a more
+ Is this the right specialty for meis it sufficiently general? realistic career choice (such as general prac-
+ Will I be able to pursue my previous specialty in the United Kingdom? tice). This will influence the doctors choice of
+ Is this the right time for me to do an attachment? attachment.
+ Is my English good enough to get the most out of it? Attachments in the more general special-
+ Does this trust or surgery understand my needs? ties such as general practice, emergency
+ Will the attachment provide a sufficiently broad range of experienceoutpatients, medicine, and general medicine offer the
wards, surgeries, etc? best preparation for the PLAB exam.
+ Will I have sufficient contact with patients?
+ If in hospital will I be able to shadow a senior house officer (the grade that doctors Timing
who gain limited registration will be able to work at)? For doctors wishing to continue in hospital
+ Will there be a learning contract? careers, more specialised clinical attach-
+ Will I meet my supervisor before the attachment to discuss ground rules and my ments may be best taken after passing the
training needs? PLAB exam. Many doctors may benefit from
+ Will there be regular meetings to debrief and review my goals? more than one attachment at different stages
+ Is there a quality monitoring mechanismwhat happens if I have problems? and with different goals.
+ Do I understand my legal position with patients? There is wide consensus that it is best to do
+ Have I made an effort to be appropriately friendly with all the staff? an attachment after passing the International
+ Will I be able to keep in touch with this unit after the attachment is overfor English Language Teaching System (IELTS)
example, to attend meetings or use the library? with the scores required by the General Medi-
+ Have I considered the effect on my welfare benefits? cal Council, to gain the maximum benefit and
ensure the best possible reference.

s160 BMJ CAREERS 16 NOVEMBER 2002

 career focus

Clinical supervisors
The clinical supervisors taking responsibility
for attached doctors will be consultants and
Personal experiences
general practitioners (GPs) with varying Doctor doing a clinical attachment (Sajid Siddiqi)
experience and understanding of the needs My clinical attachment has given me the opportunity to learn the work that I hope I will
of overseas doctors. Training for supervisors be doing in the near future. It has given me confidence. The difference between the
of clinical attachments could be undertaken SHO and myself is that the SHO has all the responsibility and the workload. I am now
in half a day, probably on a regional basis, aware of the responsibilities of the SHO without having any of the anxieties.
and cover a variety of topics (see box). It is
Working on a clinical attachment has been fantastic. I have enjoyed all the tasks I was
also helpful for the supervisors to have some
allowed to do and was treated the same way as all the other doctors by the nursing staff
basic understanding of the welfare and legal
and my medical colleagues. I always felt that I was a valuable part of the team. I personally
situation of refugees.
recommend that all newly arrived overseas doctors take up a clinical attachment post even
At the beginning if for a short period of time before working as an SHO. Doing so you would have the
It is beneficial for the overseas doctor and opportunity to watch and learn before you take on the responsibility of working as an
clinical supervisor to meet for an informal SHO. It will also be very beneficial to you when sitting the PLAB part 2 exam.
interview before the doctor is accepted for the Specialist registrar (Ignasi Agell)
attachment to make sure they both know what
I didnt know Sajid was coming to our service until the day that my consultant
is expected (at least one session a week of
introduced him to me and suggested he attended my clinic. Sajid told me he was happy
formal teaching directed specifically at the
to do anything I considered appropriate but had no idea of what that could be. The
overseas doctors training needs is considered
problem was that I didnt either. The lack of preparation meant that we quickly had to
a minimum). Once the attachment starts, the
start thinking of some options.
clinical supervisor should conduct the assess-
ments of learning and training needs in the We arranged for him to meet with me every morning and then discuss the rest of the
first week. This is a chance to set goals. These day, usually to be spent with the consultant, the SHO, or on his own on the ward
plans are put into the overseas doctors per- interviewing patients. This simple plan put a structure to Sajids days, and our meetings
sonal development plan. Thereafter, meetings became useful for both of us. I learnt of his anxieties and problems as well as of his
should take place periodically, to assess ambitions. Doctors looking for clinical attachments dont come to our service regularly,
progress, discuss any problems, and set but careful planning and discussions with the attached doctors can help them get the
further goals if appropriate. most out of it as possible.

During attachments and at the end

During attachments, overseas doctors should be encouraged; performing invasive Over the past year more funding has
should attend ward rounds, outpatients, or procedures and intimate physical examina- become available to support initiatives for
surgeries and shadow junior doctors. They tions are best avoided. As with medical stu- refugee doctors at local and national level,
should take histories and examine patients, dents, the patient must give free and which is hoped to reduce the likelihood of
although intimate examinations are best informed consent to their involvement in refugees being barred from clinical attach-
avoided (see below). Observing others work- training of any personnel and must be aware ments because of cost. Some non-refugee
ing can be a rich source of learning, but only that the doctor is not registered to practise in overseas doctors are also poor and living on
if supervisors and their attached doctors the United Kingdom. With the advent of borrowed money. Certainly profiteering
make efforts to ensure maximum benefit. structured clinical attachments with guide- from clinical attachments is not justifiable,
Overseas doctors should be allowed to lines for supervision, the medical defence given that many of these doctors are going to
attend medical meetings and use the medical unions may be able to review their position, give years of service to the NHS.
library. At the end of the attachment an exit particularly where the attached doctors have
interview should be held, and mutual feed- passed the PLAB exam, which indicates eli-
back should be given (before the evaluation). Welfare rights
gibility for limited registration in a super-
Requirements covering welfare benefits and
vised medical job as an SHO.
Ethical and legal considerations availability for work may be affected by par-
Medical indemnity matters Avoid exploitation ticipation in clinical attachments. Overseas
The supervising doctor is liable for the Safeguards against exploitation of an doctors, programme organisers, and trust
actions of the attached doctor, as the attached doctor need to be considered espe- human resources departments need to take
attached doctor has no indemnity. It is a cially where the doctor is expected to under- appropriate advice from employment and
matter of judgment about what the doctor take part time work. The limits about what training agencies in the local government
can be permitted to observe and do. Talking work is expected need to be defined. Pro- and voluntary sectors.
to patients and routine physical examination tected time for study and clinical experience
must be set aside. Anita Berlin senior lecturer
Department of Primary Care and Population
Recommended training and Sciences, Royal Free and University College School of
Who pays?
Medicine, London N19 5LW
support for supervisors Some trusts in the past have charged all over- a.berlin@pcps.ucl.ac.uk
seas doctors for clinical attachments. But
+ Clarification of purposes of clinical many clinicians have offered excellent clinical Sheila Cheeroth clinical lecturer and head
attachments attachments for years for no remuneration. If Refugee Doctors Programme, Department of General
+ What is a refugee or asylum seeker or supervisors or their trusts expect to be paid Practice, Barts and the London, Queen Marys School
overseas doctor? the risk is that this cost will be transferred to of Medicine and Dentistry, London E1 4NS
+ Routes to reregistration (such as the overseas doctor or the voluntary sector.
IELTS, PLAB) It may be that points in continuing medi- Ignasi Agell specialist registrar in psychiatry
+ Legal aspects and access to patients cal education (CME) could be awarded for
St Lukes Hospital, Huddersfield HD4 5RQ
+ Checklist for initial interviews iggy@agell.freeserve.co.uk
taking a doctor on clinical attachment, but we
assessment of needs are uncertain to what extent this would be an Sajid Siddiqi overseas doctor doing a clinical
+ Model timetable incentive. The NHS Executive encourages attachment in psychiatry
+ Strategies for maximising learning trusts and GPs to provide clinical attach-
opportunities for the attached doctor ments free of charge to medically qualified 1 Cheeroth S, Berlin A. BMA guidelines for overseas quali-
+ Giving feedback refugees and asylum seekers and to provide
fied doctors. London: BMA, 2001.
2 Department of Health. Report of the working group of
help with accommodation where possible.2 refugee doctors and dentists. London: DoH, 2000.

BMJ CAREERS 16 NOVEMBER 2002 s161

career focus

Passing the IELTS exam

Tony Fitzgerald explains the different components and gives some helpful tips

T
he IELTS (International English Lan- example, the Cambridge Skills for
guage Testing System) examination Fluency Listening Series or the
tests the skills needed for academic Headway or Cutting Edge series
study in the United Kingdom. The test com- ranging from elementary to advanced
prises four components: listening, speaking, levels.
reading, and writing. Each component is + Listen to material that includes people
scored individually and an overall score is speaking in a variety of accents.
awarded. It is not a pass/fail exam but is + Familiarise yourself with the way words
banded from 1 to 9, with 1 indicating a very are shortened, stressed, and flow into
rudimentary knowledge of English and 9 each other in typical everyday speech
indicating language skills equivalent to those (Headway has a series of books on true/false/information not available; sum-
of a native speaker. pronunciation). mary gap-fills; selection of appropriate head-
The General Medical Council (GMC) asks ings for paragraphs or sections of the text;
overseas doctors for an overall score of 7.0, Writing completion of diagrams. Candidates have one
with a score of at least 7.0 in the speaking The candidate is asked to carry out two tasks. hour to read the text and answer the ques-
component and a score of no less than 6.0 in Task 1 involves writing a report based on tions. Texts and tasks become increasingly
each of the other three components. A information or data presented in a diagram difficult.
doctor can then apply for the two parts of the or table form. Tips
PLAB (Professional Linguistic Assessment Task 2 involves writing an essay on a given + Read regularly, especially journals or
Board) exam. topic of general interest. Common topics magazines that contain articles with an
Candidates can sit the exam in centres include the impact of the modern world on academic focus.
worldwide. Throughout Britain, centres run the environment; the role of education in + Read for gist first. Use the title, headings,
the exam on a regular basis. There is no limit society; the consequences of population introduction, conclusion, and the topic
on the number of times a person may sit the growth; and the effects of new technologies. sentences of each paragraph to acquire a
exam, though a candidate is not allowed to sit Candidates have 40 minutes to write at least general understanding of a text.
it within three months of a previous attempt. 250 words. + Distinguish between questions that
Tips for task 1 require you to scan for specific
Preparing for the examination + Look carefully at the figures before you information; those asking for an
Preparation courses for the IELTS exam are understanding of the gist; and those that
begin to write. Is the chart showing
run in many colleges and universities across require close, detailed reading.
numbers or percentages? This may
Britain. Some courses specifically cater for + Identify the key phrases in both the text
determine the grammatical structures
the needs of overseas doctorsfor example, and the questions.
you need to use.
Southwark College, Barnet College, and + Be strict in allocating and adhering to a
+ Be clear about which verb tense (or
Westminster Adult Education Centre in the time by which you will answer each
tenses) to use.
London area. (For further information about
+ Write a sentence that presents an overall section of questions. If you cannot
these courses, see the newsletter issued by answer a question within the time you
analysis in general terms of the
the BMA for those doctors on the Refugee have given yourself, move on to the next.
information presented in the chart.
Doctor database.)
+ Make sure that you understand the
Preparing for each component grammar of the verbs (and associated Speaking
adverbs) used to describe trends, such as The speaking module involves an oral inter-
Listening increase/decrease; rise/fall; raise/reduce view with an examiner, lasting 11-14 min-
The candidate listens once to four extracts of (slightly, gradually, significantly, utes. The module has three main parts. In the
spoken English, often dialogues or short markedly). first, the candidate answers general questions
lecturesfor example, an introductory lec- about his or her home, family, jobs, studies,
ture welcoming students on to a course or Tips for task 2
and interests. In the second, the candidate
two students discussing timetables. The can- + Before starting, analyse the essay title. Is
has to speak for two minutes on a topic given
didate has to answer 10 questions (multiple it asking for an opinion, reasons for and
on a card. In the third, the examiner and the
choice, short answer questions, summary against a point of view, the advantages
candidate hold a conversation on more
gap-fills, or complete flow charts) on each and disadvantages of something? This
abstract issues related to the topic spoken
extract. The texts become increasingly diffi- will affect how you structure your essay.
about in the second part.
cult as the test progresses. + Decide on your opinion and plan the
The skills required are the ability to listen essay before you start to write. Tips
and simultaneously record the main or key + Avoid long sentences: the longer the + Dont rush your answers. The examiner
points heard; to note correctly important sentence, the more difficult it becomes to is looking for the ability to create a
numbers or dates mentioned; to recognise control the grammar. spoken argument that links ideas and
subtle shades of expression; and to follow + Learn the rules of punctuation, language logically together.
descriptions of procedures or processes. particularly commas. + If you dont know or cant remember a
+ Make sure that you understand the word that you need, try to find a close
Tips difference between conjunctions (for alternative or words that explain it.
+ Immerse yourself in spoken English as example, and, so, and but) and + Prepare for the interview, but dont
much as you can. Listen regularly to connecters (for example, furthermore, memorise responsesfor example, think
radio and television. Radio 4, for however, in addition, and similarly). about what your interests are and how
example, offers a range of broadcasts on + Leave two or three minutes at the end to those interests have developed.
current affairs, science, education, and check for common mistakes. + Avoid one-word answers, particularly at
medicine in which you will hear the type the beginning of the interview.
of vocabulary needed in the test. Reading
+ Make use of the vast amount of listening The reading section comprises three articles Tony Fitzgerald Medical English course
material that is available for students on which candidates have to answer 40 ques- coordinator, Barnet College, London NW9 5RA
studying English at all levelsfor tions in total. The question types include: Tony.Fitzgerald@barnet.ac.uk

s162 BMJ CAREERS 16 NOVEMBER 2002

 career focus

Preparing for the PLAB test

Wai-Ching Leung gives some advice on how to prepare for both parts

M
ost overseas doctors from outside possible in answering them. Many self
the European Union are required to assessment books consist of questions
sit the Professional and Linguistic for either the PLAB or medical final
Assessments Board (PLAB) test before they examinations (available from internet
can practise medicine in Britain. The PLAB bookshops and the BMJ bookshop)

SUE SHARPLES
test is specifically designed to assess a doc- + Familiarise yourself with the format and
tors ability to work safely as a senior house the instructions on the marksheet used
officer (SHO) in a British hospital. in the PLAB test. You will find a
specimen copy in PLAB part 1advice
Part 1 of the 14 stations, and must not have a grade
Part 1 is a three hour written paper consist- to candidates.
E at more than one station.
ing of 200 extended matching questions. The
emphasis is on clinical management and the Part 2 Tips on preparation
ability to apply knowledge to the care of Part 2 can be taken only in the United King- + Arrange a short clinical attachment in
patients. It includes: diagnosis; investigations; dom. Exam sessions are run 10 times a year. the United Kingdom before your test to
management; the context of clinical practice. You must pass your part 2 within two years of help familiarise you with: how doctors
In the first three areas, you are usually given passing your part 1, and you are allowed a interact with patients in Britain; the legal
important information about a patient and maximum of four attempts. Otherwise you and ethical advice in Duties of a Doctor4
asked to select the most likely diagnosis, or the have to sit the part 1 and IELTS again. and Good Medical Practice put into
most appropriate investigation or manage- Although the official closing date is just over practice2; the colloquial terms commonly
ment from a list of options. The last area two weeks before each test, the sessions are used by patients; and the equipment
includes ethics and law, evidence based medi- often overbooked so it is wise to apply early. routinely available
cine, epidemiology, and health promotion. Part 2 consists of a objective structured + If possible, enrol on a PLAB part 2
clinical examination (OSCE) with 14 stations course with practice OSCE
Tips on preparation and tests your clinical and communication + Alternatively, ask your senior colleagues
+ Draw up a revision plan skills. You are examined for five minutes at to give you five-minute mock station tests
+ Revise from concise textbooks or each station. There are two rest stations, and + Get access to a clinical skills laboratory
handbooks published in the United the whole examination lasts 96 minutes. You and practise the practical skills listed on
Kingdom, such as the popular Oxford are assessed on your clinical management of p 32 of PLAB part 2advice to
series. Use large textbooks only to look conditions seen across a range of medical candidates
up specific points and surgical areas commonly seen by junior + Drill yourself thoroughly on the
+ Revise thoroughly: doctors. The five main skills tested are: management of common emergency
Characteristic symptoms, signs, and + Taking a history and reaching a conditions such as basic adult and
investigation results of common diagnosis paediatric cardiopulmonary resuscitation
conditions + Carrying out a physical examination and
General principles of management of recording your findings Tips on taking the test
emergency conditions, as well as for + Communication Before each station, you have one minute to
common conditions such as acute chest + Performing practical skills read the instructions, which tell you what you
pain + Managing emergency situations. need to do. Read them carefully and men-
+ Dont spend too much time on the rarer At most stations, you will be demonstrating tally plan your approach. Aim to complete
conditions that might appear only in these skills on manikins, models, or standard- the task within five minutes. Note whether
postgraduate examinations ised patients (actors who give a history or you should address the standardised patient
+ Carefully study Good Medical Practice2 display symptoms according to a predeter- or the examiner.
+ Get an up to date copy of the British mined script). Carry out the tasks efficiently. But dont
National Formulary. Note any differences At each station, you are assessed on a rush, and pay attention to the communica-
in the names of drugs from those that number of objectives in the five skill areas. tion aspects. Spend the first 30 seconds
you are used to in your country But you are not told of the objectives you are establishing rapport.
+ Read reviews of management of assessed against at each station. You will hear a warning bell 30 seconds
common conditions in journals such as You will be given a grade from A to E for before your allotted time at each station. Make
the BMJ, and Postgraduate Medicine each objective. Each of the objectives may good use of the remaining time to mention
+ Familiarise yourself with the format of carry different weights, and an overall grade any other key points or perform key tasks.
extended matching questions.3 It is is calculated. To pass the test, you must obtain When you move to the next station, con-
essential to get as much practice as an overall grade of C or above at 10 or more centrate on the tasks ahead and forget what
happened in previous stations.

Before applying for the PLAB test Wai-Ching Leung locum general practitioner
+ Make sure you really want to work in the United Kingdom1 Tyne and Wear
wai_chingleung@hotmail.com
+ Check with the General Medical Council that your primary medical qualification is
acceptable for limited registration and that it does not qualify you for automatically 1 Suresh K. Surviving as an overseas doctor1: Coming
for full registration to the United Kingdom. BMJ (suppl) 2002;325:S39.
+ Make sure you have got the required score in the International English Language http://bmj.com/cgi/content/full/325/7358/S39
2 General Medical Council. Good medical practice.
Testing System assessment (IELTS) examination London: GMC, 2001. www.gmc-uk.org/standards/
+ Plan when and where you are going to take the test. Part 1 is held six times a year and default.htm (accessed 17 Oct 2002).
can be taken both in the United Kingdom and overseas (currently Bulgaria, Egypt, 3 Leung WC. Computer marked written examinations.
BMJ (suppl) 2002;324:S73. http://bmj.com/cgi/
India, Nigeria, Pakistan, and Sri Lanka). Apply early to make sure you will get a place content/full/324/7337/S73a
+ Read the documents PLAB part 1 and 2advice to candidates (available for 4 General Medical Council. The duties of a doctor registered
download at www.gmc-uk.org) with the General Medical Council. London: GMC, 2001.
www.gmc-uk.org/standards/default.htm (accessed 17
Oct 2002).

BMJ CAREERS 16 NOVEMBER 2002 s163

career focus

Postgraduate exams: the MRCP(UK) Tips on . . .

Postgraduate examinations are another hurdle that overseas doctors have to
pass. Jim Benson addresses their concerns about the MRCP(UK) Preparing for the MRCP
part 1
T
he MRCP(UK) (Membership of the postgraduate degrees, diplomas and courses in
Royal College of Physicians in the medicine. This is published annually and is
United Kingdom) is a prerequisite for available from the National Advice Centre for (1) Its never too early to start studying.
doctors wishing to undergo higher training Postgraduate Medical Education. The centre Do not expect to do well if you
in a medically related specialty. The aim is to can provide impartial advice on registration, procrastinate and cram a week or two
identify those doctors who, having under- clinical attachment, availability and suitability before the examination.
taken a period of general training, have of courses, and careers guidance. The colleges (2) The intelligent use of basic principles
acquired the necessary professional knowl- themselves run courses that are readily acces- and pathophysiology along with careful
edge, skills, and attitudes to enable them to sible to overseas candidates (see individual thought often proves more rewarding
benefit from a programme of higher special- college websites for details). than just cramming.
ist training in the United Kingdom. The
MRCP(UK) assessments must reflect these Catching candidates out? (3) Use all your spare time to practise
Many candidates are under the impression questions; there are many books
needs.
that the MRCP(UK) has been devised to catch available with practice questions to
Are there national differences in pass rates? them out in some way. The MRCP(UK) regu- stimulate the mind.
At present I cannot give any meaningful pass lations and information for candidates give (4) Revision courses can assist
rate analysis for any nationality or ethnic precise details about what will be tested. Past tremendously by reviewing key
group, as we do not have a high enough MRCP(UK) examination papers are also specialties and preparing you for the
response rate to our requests for this infor- available. format of the test. Look for courses that
mation (it stands at around 35% at the We make every effort to ensure the offer small class sizes so you can interact
moment). MRCP(UK) is delivered as stated, so candi- with the lecturers without feeling
However, a recent report said that pass dates should focus their examination prepa- intimidated.
rates for all the royal college exams ranged ration on this. If we do not deliver the
MRCP(UK) as we say we will, this is a proce- (5) Online courses often allow you to
between 44.4% and 78.8% for British gradu-
dural defect, and the colleges have intro- take practice tests that simulate the
ates and 28% to 66.7% for non-British
duced an appeals procedure to address any testing conditions on the day of the
graduates.1
such complaint. sitting, as well as more structured
MRCP(UK) developments Candidates should not be afraid to ask for subject-based revision. Look for courses
The MRCP(UK) policy committee aims to clarification on any aspect of the MRCP(UK), that update the material regularly, and
ensure that developments of the examina- and an invigilator or clinical examiner will check who is writing the material.
tion (such as the introduction of a standard- not penalise you for seeking clarification. (6) Practice mock-exams under time
ised clinical examination, the Practical constraints and work out the best
Assessment of Clinical Examination Language strategy that works for you: think fast,
SkillsPACES) are relevant and appropriate We do not apply any language test as a and commit yourself to an answer for
for all who seek the MRCP(UK). requirement for taking the MRCP(UK), but each question. Only leave out those
We recognise that in offering the we do advise candidates that language ability questions that are puzzling you. When
MRCP(UK) as an international examination, should be equivalent to International Eng- you finish, go back and try these again.
the needs and concerns of doctors from out- lish Language Testing System assessment
(IELTS) level 7 in each module. (7) Read the question carefully. Many
side the United Kingdom must be taken into
mistakes are due to misreading true for
account.
Feedback false, hyper for hypo and vice versa, etc.
The recent developments of the
We do appreciate hearing your views on the Remember: questions with the phrases
MRCP(UK) were taken forward on the
MRCP(UK). Processes such as the appeals always and never are usually false.
advice and approval of our overseas col-
procedure have been developed to review (8) Do not to spend too much time on
leagues. This means that the MRCP(UK) can
individual cases and formally take account of one item. Answer every questionthere
complement overseas postgraduate provi-
your concerns. Informal observations are also is no negative marking.
sion and be a relevant international medical
useful and may lead us to consider revising the
examination. (9) Often, responses that you were
examination.
extremely confident about will appear
Concerns Finally less convincing the more you go over
Correspondence I have had with overseas them. Remember that your first
If you fail the MRCP(UK) look at the reasons
doctors interested in obtaining the judgment is usually correct.
for this. Detailed feedback is provided with all
MRCP(UK) indicates their concerns and
our assessments and this is perhaps the best (10) Leave time at the end to make sure
misconceptions about the best strategy to
guide for preparation and future success. If you have transferred your responses to
employ for taking the examination.
you consider that you would benefit from a the answer sheet correctly.
Studying for the exam counselling session after failure in the clini-
Some overseas doctors are concerned at what cal examination (PACES) please contact Sabine Guerry director
they perceive to be high fail rates for non- your college of entry, whose staff will do their 123Doc Medical Courses
best to arrange this. We are always prepared Sabine@123Doc.com
British nationals. I would advise overseas doc-
tors to take any opportunity that they might to explain the reason for failure of any part of Career focus has 10 free monthly subscriptions
have for gaining a working knowledge of the the MRCP(UK). (value 25) to a part 1 (MRCP or MRCPCH)
United Kingdoms healthcare system. online e-course (provided by 123Doc Medical
We advise candidates to prepare for the Jim Benson head Courses, www.123doc.com). All you have to do
MRCP(UK) Central Office, 11 St Andrews Place, is answer the following: How many questions
examination by gaining clinical experience in
Regents Park, London NW1 4LE can you access from 123Doc website when you
managing emergency medical patients and by www.mrcpuk.org subscribe for an online course? Please email
studying up to date postgraduate clinical text- careerfocus@bmj.com (winners will be chosen
1 Donaldson L. Unfinished business: proposals for the reform
books and current medical journals. Details of the senior house officer grade. London: Department of from correct responses).
of courses are contained in the Guide to Health, 2002. www.doh.gov.uk/shoconsult

s164 BMJ CAREERS 16 NOVEMBER 2002

 career focus

Spruce up your CV and interview skills Some CV donts

Sonia Hutton-Taylor gives some advice that may help overseas doctors + Do not use the same CV for every job
application (if you do this, you are
secure their first post
not targeting appropriately)
+ Do not include copious details about

Y
ou can use many tricks and tips to your own specialty to read through the docu-
improve both your CV presentation ments and point out anything that looks odd schooling on the front page
and interview performance. UK gradu- or things you could do to improve it. + Do not repeat the same information
ates may pick up some of these in medical A main problem in seeking advice, how- under several job headings
school, but overseas doctors can be at a dis- ever, is the possibility of receiving conflicting + Do not write huge paragraphsthat
advantage as they may not know what CVs feedback, which can seem confusing. If there is, more than five linesof unbroken
and interviews in Britain are really about. is no consensus in the opinions offered, you text; bullets are better
It is vital for success in both your CV and need to assess for yourself which infor- + Do not use a chatty stylea CV is a
your interview to prepare well by learning as mation seems right for you. professional presentation
much as possible about the employing body, + Do not make grammar and spelling
the bosses, the unit, and the job, etc. An What if your CV is not working? mistakes
effective CV should be written only after a If you are not being shortlisted despite sub- + Do not adopt poor chronology. You
thorough analysis of the job specification, mitting numerous CVs, this may be because: should start with current jobs and
person specification, job advertisement, and + Your CV is not selling you as well as it work logically backwards
trust or practice website. could + Do not use inappropriate
+ The posts you are targeting are very terminology
Curriculum vitae competitive and attracting many high + Do not use an inconsistent
This is your sales documentinformation calibre candidates layoutfor example, fonts, headings
about you that allows the selection panel to + You are applying for the wrong job for
decide whether you have the skills, personal your particular level of skills and
attributes, experience, and qualifications for experience. DuringUse good eye contact with the
the post being advertised. After a few applications have been rejected, it interview panel and smile occasionally. Dont
Many overseas doctors come from very is worth doing something differentlyfor give short monosyllabic answers, but equally
different cultures and medical systems, example, seek some further careers advice or dont ramble or be repetitive. The right
where qualifications and years in post can restructure your CV. It is common for a CV length and balance of answers is almost as
be strong factors in appointment. It is a to have to go through many drafts before the important as the content.
common mistake to think that merely listing final version. AfterWrite down all the interview ques-
experience and qualifications is enough. tions (and your answers if you can recall
These days it is not. Certainly without these Interviews them) immediately you come out of the
you are unlikely to get shortlisted or Some people are just born performers and room. This will allow you to start building an
appointedbut with stiff competition the sales people, so coming across well at inter- interview question bank and help you to
final decision can rest on more generic skills, view is easy for them. However, many more pinpoint the questions where your answers
such as evidence of teamworking and teach- are either very nervous or generally unpre- are letting you down. If you dont get the job,
ing, which will need to come under an addi- pared, and so they may not be offered the ask for some feedback from the interview
tional skills subheading. jobnot because they are unqualified or panel either on the day or by calling back
CV building is the process of identifying unable to do the job but because they cant later in the week. The human resources
what is missing on your CV and then taking convince the panel that they have what is officer on the panel may be better at doing
on specific responsibilities or experiences so needed. Doctors often think that selling and this than the doctors.
that you can fill in these gaps. salesmanship is beneath them, yet being
What interviewers want
able to influence and persuade others is a key Shortlisting may be based on criteria such as
Application forms skill for doctors in many aspects of their qualifications, paper experience, and aca-
Currently, an increasing number of posts career. demic flair, but interviewers are aiming to
have an application form either in addition Interviews are about selecting the best find out a lot more than this. They want to
to or instead of a CV. An application form person from the candidates being inter- find a confident and competent person who
allows the selection panel to have infor- viewed. They are competitions and therefore can show that they know what the job entails
mation about candidates in a standardised warrant some time spent in preparation and but also be aware of their own limitations and
format, which makes comparisons between training. know when to seek help.
candidates easier and also finding relevant
information easier. The disadvantage to the Techniques Sonia Hutton-Taylor founder
candidate is that there is less room for crea- The technique for doing well at interviews Medical Forum Career Management
tivity and a greater requirement to be suc- can be learned with practice. For some doc- www.medicalforum.com
cinct. Application forms also tend to ask tors this means having to go through a few Competing interest: Medical Forum is an inde-
more essay-type questionssuch as give an unsuccessful interviews to learn the ropes. pendent career support facility for doctors, and
example of how you deal with a difficult But doctors who have fundamental prob- SH-T receives income from consulting work and
patient or explain a case where you feel you lems with interview technique may need to speaking engagements related to medical human
learnt a lot. This format is considerably have many weeks or months of organised resources.
more searching than a CV, where you are interview practice and perhaps some one to
merely listing jobs, procedures, and papers. one training. The following tips may help. Further information
The answers people give are often much BeforeBe sure to read through your CV + Lectures on CV and interview skills are
more revealing than they realise. (the copy that you sent for this particular often included in deanery induction
job), application form, and job description courses for overseas doctors
Get it edited the night before or on the way to the inter- + How to structure your CV
Once you have completed your CV and/or view. Take any other documents with you (see www.medicalforum.com/
job application get several people to read that might be usefulfor example, copies of CV_headings.html)
through it. Firstly, ask someone who has any research papers that you have contrib- + Common interview questions
excellent spelling and grammar to check for uted to, health certificates, or work permit (see www.medicalforum.com/
mistakes. Secondly, try to find a doctor in information. interview_qlist.html)

BMJ CAREERS 16 NOVEMBER 2002 s165

career focus

Refugee doctors in the United Kingdom The DSS [Department of Social

Security, now part of the Department
Emma Stewart discusses the main problems encountered by refugee and for Work and Pensions] provides
asylum seeker doctors in the United Kingdom. Her findings are based on support for refugees, but its not easy for
35 in-depth interviews. Sallie Nicholas explains what the Refugee Doctor a refugee doctor to work as a waiter . . .
The job centre wont accept that you are
Liaison Group is and how it can help looking for a medical post. They say that

M
any refugee doctors face profes- But job centre regulations often do not rec- you need to find a job, any job, and that
sional disappointment, frustration, ognise the unusual situation of refugee doc- they dont care about the qualifications
and humiliation. The professional, tors who are seeking medical employment. that you may have from your country of
financial, and cultural obstacles facing refu- The result is that they may be forced to take origin. (Male refugee doctor from
gee doctors have been well documented over an unskilled post, resulting in the deskilling Middle East)
the past five years.13 of some doctors.
Mohammeds case is typical. He is a quali- Although the UK government has allo-
fied doctor from the Middle East with over 20 enter a full time medical post. Most doctors
cated 500 000 ($773 000; 795 000) to
years specialist experience, including con- felt they were disadvantaged at the shortlist-
enable refugee doctors to take up unpaid
sultation for worldwide organisations. He ing stage and that preference was always
clinical attachments,4 the doctors highlighted
fled his country of origin for fear of his life. given to local candidates.
problems with this. Firstly, if the posts are
But since Mohammed has been in the
unpaid what is the person expected to live on?
United Kingdom he has been able to get only Career progression
Secondly, if, as the BMA estimates, there are
a staff grade post. He is extremely frustrated Once a refuge doctor is working in the health
500 to 2000 refugee doctors then this funding
that he has no opportunity to progress service, the problems do not necessarily stop.
will provide only 250 for each person. The
beyond this and use his specialist knowledge. There may be stagnation in the middle
estimated cost for courses and exams to
I conducted 35 in-depth interviews with grades as they cannot get training posts but
requalify as a GP is 3500,5 so the government
refugee and asylum seeker doctors through-
would need to spend at least 7m. are forced to take a staff grade or associate
out Britain to investigate their professional
specialist post. Otherwise they may only gain
experiences.
jobs in the less popular specialties which
The doctors made it evident that the road
We were asked to wait for six months other candidates do not want. Their overseas
to restarting their career in Britain is fraught
for decision with the GMC . . . Six experience seems to count for nothing.
with many obstacles and hurdlesnotably,
months later they said you have to take There is a feeling that it is very difficult to
the General Medical Councils (GMC)
PLAB exam. The next exam was six proceed to consultant level despite being
requirements, including the International
months later because you cant take it over-qualified. And if they do ever reach con-
English Language Testing System (IELTS)
just tomorrow. (European refugee sultant level, this is unlikely to be in teaching
examination and the Professional Linguistic
doctor, male) hospitals.
Assessment Board (PLAB) exam; unemploy-
Refugee doctors perceive that the system
ment regulations; being shortlisted for jobs; It was really hard because IELTS is not
allows preference to be given to local candi-
and career progression. a question of knowing English, it is a
dates. Some doctors also reported preferen-
question of passing it as a specific exam
tial treatment of European doctors, which
GMC requirements . . . I have seen many doctors in London
The route to GMC registration is long and causes resentment. Despite the fact that
who are here already five years or four
complex. Many individuals said that the many refugee doctors education was in Eng-
years. They cannot work because they
exams (IELTS and PLAB) taken before regis- lish, they must still take the IELTS exam.
have tried to pass that exam; they
tration were problematic. They felt that the European candidates, however, are exempt
cannot pass it, although their English is
cost and especially the time between exams from this exam, which annoys refugee doc-
perfect. They can write correctly English,
was frustrating. The preparation for exams tors who personally witness the poor English
but it is impossible for them to pass that
such as the PLAB was also hindered by a lack performance of some Europeans.
test. (Male African refugee doctor)
of direction and specific textbooks.
IELTS is very difficult for me to pass Personal issues
Unemployment regulations because it really doesnt evaluate your Many personal issues also face refugee doc-
The interviewees spoke of difficulties after knowledge of English or how you can tors. Firstly, they have to adapt to the NHS. All
doctors have passed their exams. Once a communicate to your patients or how individuals mentioned that the lack of family
doctor has refugee status they receive social you can go on in your career. Its a very support can make life problematic. The lack of
security benefits and must be ready for work. general thing. (Female asylum seeker both professional and personal networks
doctor from Middle East) makes initial integration difficult. There are
also problems in adapting to a different cul-
ture and living in a foreign country.
Being shortlisted for a job
The GMC provides only limited registration
when a doctor has a job offer. Refugee doc- I applied for registration and the GMC
tors noted considerable difficulties in com- registered me through the senior doctor
peting with other candidates when they do route, and Ive been applying for
not have GMC registration and the UK ref- specialist registrar jobs to be retrained
erences needed. They explained that the and Ive not even been shortlisted . . .
time spent leaving a country and requalify- Taking into account that those who are
ing means not only are they older but they competing with me are the fresh
also have a gap in their CVs. They also have graduates and SHOs who have just
done some basic training or practice
GARRY HUNTER/PHOTONICA

the initial professional disadvantage of not

practising medicine for a while, so some doc- and have no experience, I find this very
tors in specialties such as surgery may lose disappointing and frustrating . . . Im
their touch. And, despite government meas- trapped here to be on the dole. (Male
ures to speed up the process, most of those refugee doctor from Middle East)
interviewed said that it took them years to

s166 BMJ CAREERS 16 NOVEMBER 2002

 career focus

The Refugee Doctor Liaison Group

The Refugee Doctor Liaison Group (RDLG) brings together large national
organisations, small local groups, and individuals involved in running study groups,
teaching English, or offering support in other ways. The group serves as a forum for
networking, information exchange, and collective action wherever possible. In many
ways, it has acted as a catalyst. The Department of Health attends all meetings.

Recent developments involving members of the group

Voluntary database The BMA and the Refugee Council have set up a voluntary
database of refugee and asylum seeking doctors. We update and circulate statistics every
month to give all those involved in helping refugee doctors the fullest possible picture of
their numbers, locations, and needs. Doctors on the databasewhose personal details
are held in complete confidentialityreceive a quarterly newsletter, Refugee Doctors News,
plus targeted information about local events. See the BMAs website (www.bma.org.uk)
for forms or contact its international department (tel 020 7383 6133; email:
internationalinfo@bma.org.uk).
Information pack The Jewish Council for Racial Equality has updated its previous
MATTHEW SEPTIMUS/PHOTONICA

guide for refugee doctors to form a comprehensive resource document. It is available

from the BMAs international department.
Clinical attachments These are invaluable in helping refugee doctors to get first hand
experience of the NHS but can be difficult to find. Some trusts charge for them, and
there is often confusion about how they should work. The BMA has published and
disseminated guidelines written by two members of the RDLG (see BMAs website or via
the international department). Some of the royal colleges are encouraging their
However, the most notable personal members to provide attachments.
impact on doctors was the emotional and Postgraduate deaneries and regional networks The deaneries have become
psychological effects of being undervalued increasingly involved in helping refugee doctors in their areas. Many have organised
as a doctor in Britain. Many doctors special courses or events, and their involvement is making a real difference. The
explained the severe mental effect of being Department of Health has set up a database of refugee doctor links on its website
devalued, underused, and deskilled. One (www.doh.gov.uk/medicaltrainingintheuk).
main contributing factor to this was the time Positive publicity Both the medical press and the national media have shown a marked
taken to re-enter the profession. The doctors increase in interest and positive coverage. We have worked to generate and foster this.
interviewed expressed a real feeling of frus- PLAB test The GMC has waived fees for the first two attempts at part I of the PLAB test
tration, demoralisation, and hopelessness, for refugee doctors. The Refugee Doctor Postgraduate Centre in Hendon, London, has
echoing the following sentiments: the men- set up a distance learning programme (see www.plabisgood4u.com).
tal anguish and physical deprivation, the
Free membership benefits The BMA has set up a special package of benefits for
sense of annihilation and loss of reference
refugee doctors working towards registration in the United Kingdom. This includes a
points, and the vulnerability and desperation
weekly copy of the BMJ (see www.bma.org.uk or contact the BMAs international
of refugees . . . the language difficulties, the
department). The medical defence organisations offer free or reduced membership.
lack of relatives and friends and knowledge
of the system, the uncertainty and the daily If you are a refugee or asylum seeking doctor and you have not already done so, please:
struggle for survival and to keep ones sanity + Look at the Department of Healths website for details of contacts in your area
and integrity; all these reduced life to a mis- + Contact us to register on the BMA/Refugee Council voluntary database
erable existence. + Contact us to apply for the free package of benefits
6 + Show this article to others who may not know what is available.
If you are not a refugee but would like to contribute, please:
+ Look at the Department of Healths website for groups in your area who might
I think that the thing is that nobody welcome your help
considered what experience Ive had + Consider offering a clinical attachment to a refugee doctorcontact your local
overseas at all . . . I worked as a doctor deanery if you can help
for 14 years. They consider only the past + Consider inviting refugee doctors in your area to postgraduate meetings, BMA
six years as my medical career . . . I have divisional meetings, or other gatherings.
16 years experience as a doctor . . . and I There is a great deal of interest and goodwill, and we have made enormous progress. In
find myself working with people who our excitement, however, we have not forgotten that we have raised refugee doctors
have only just graduated. (Qualified expectations and must now keep up the momentum
female doctor from Middle East)
Sallie Nicholas international department, BMA
Snicholas@bma.org.uk

potential of this group is being lost. More 1 Adams K, Borman E. Helping refugee doctors. BMJ
Conclusion 2000;320:887-8.
The refugee doctors in my research spoke must therefore be done to help refugee doc-
2 Berlin A, Gill P, Eversley J. Refugee doctors in Britain: a
clearly of the prejudice experienced at every tors to overcome the hurdles so that they can wasted resource. BMJ 1997;315:264-5.
level in the NHS. Some have been successful fully enter the health service at a time when 3 Cheeroth S, Goraya A. Refugee doctors. BMJ
2000;321(suppl):S2 (Career Focus, 21 October).
and are content, but most were not. The the NHS is clearly desperate for doctors.
4 Gavin M, Esmail A. Solving the recruitment crisis in UK
problematic issues faced in the system may general practice: time to consider physician assistants?
be more widely experienced by other over- Social Policy and Administration 2002;36(1):76-89.
Emma Stewart research postgraduate
5 Elliot P. Hidden talents. Health Service Journal
seas qualified doctors. Although measures Centre for Applied Population Research, University 1997;17:28.
have been taken to open the door to refugee of Dundee DD1 4HN 6 Ezsias A. Refugee doctors face enormous difficulty. BMJ
doctors within the United Kingdom, the full E.S.Stewart@dundee.ac.uk 1998;316:1095.

BMJ CAREERS 16 NOVEMBER 2002 s167

career focus

gibility for applying for a mortgage. If you

What to do before you come to the UK and when are renting, it is better to go through a recog-
nised agent than negotiate yourself.
you first arrive Health
Manoj Kumar has experience of coming to Britain to work, and he gives General practitioners are the first point of
some practical advice contact for any health problem, so one of the
first things you should do is register with a

I
f you are thinking of coming to work in (Professional Linguistic Assessment Board) general practice close to where you live, espe-
the United Kingdom you need to con- examination is now held in many other cially if you have a family. Be aware of the
sider several work related issues before countries, more and more younger doctors working hours of the practice. Acute prob-
making a final decision, but you should also are coming to the United Kingdom to sit lems out of hours are usually dealt with by a
be aware of what life will be like for you and part 2, which can only be taken in Britain. separate on-call service accessed through the
your family once you get here. Many overseas doctors, however, come to same phone number for the practice. In case
Britain after postgraduate training in their of an emergency, dial 999 through any
Why come to the UK? chosen specialty in their own country. This phone network and the ambulance services
Doctors from less developed countries come can result in better CVs and the advantages will respond. The same number also gets you
to the United Kingdom for training, suppos- of having prior experience in a specialty. On access to the police and the fire brigade.
edly because training is poorer or non- the other hand, it would be difficult to change
existent in their own countries. But many specialties if your chosen one is a no-go zone Crime
come here for a better life and to live in a for career progression in Britain. Though life in the United Kingdom is gener-
Western democracy with all the benefits (and Before you comeDecide if it is the right ally safe, you may at some point be the victim
some disadvantages). time in your life to make a new start. of crime. A lot of crime can be prevented by
Professionally though, they want to taking simple precautions, such as not leaving
choose the specialties they train in and to do Sociocultural aspects the doors and windows open or unlocked,
well in them. However, often the professional Families from different cultural and religious especially at night. Most crime is against prop-
and personal reasons dont fit together. To backgrounds often face a dilemma when erty and not against people, and any valuables
live here, overseas doctors often have to bringing up children in an environment that you own must be properly insured. Burglary
choose between working in a different spe- they cannot fully identify with. Many over- and theft of cars, car stereos, and mobile
cialty and trying to find success in their origi- seas doctors find themselves socially isolated phones are the likely crimes that you may
nal choice of specialty with the risk of not even when they are professionally happy, encounter, and you should report any crime
being able to stay on. This is not an easy and the balance of personal versus social (including racial attacks) to the local police.
decision, but if doctors have a realistic idea happiness may be a hard one to achieve.
about their chances of career progression Before you comeThink about the future Schooling
before they come here, then they are less when your children may grow up with values League tables of performances of schools are
likely to be disappointed. different from yours. available from local education authorities.
In other words, if its a life in Britain that
you want, you may have to choose a specialty Essentials to know before coming over Driving
in which you have a realistic chance of pro- The following is the basic minimum. Most doctors wish to have a car for practical
gressing. If it is training in a particular spe- + Immigration and employment (visa, reasons, and some of the jobs in the commu-
cialty that you want, you might have to return work permit) rules (click on nity require doctors to drive. Knowledge of
home after you get the basic training in it. Immigration & Nationality at the law is essential, and reading the Highway
There seems to be a lag period before the www.homeoffice.gov.uk) Code is a must. Even if you have driven
awareness of the opportunities in each spe- + Registration with the General Medical elsewhere, it might be useful to take a few
cialty reaches other countries. Though higher Council (www.gmc-uk.org) driving lessons from approved instructors.
training has become more structured since + The various roles of the British Council Even if your licence allows you to drive in
the Calman recommendations,1 bottlenecks (www.britishcouncil.org) Britain, it is worth passing the driving test to
exist. The widespread publicity about staff + The role of the National Advice Centre get a UK driving licence.
shortages in the NHS might also be sending for overseas doctors (www.britcoun.org/
conflicting signals to overseas doctors. health/nacpme/index.htm) Mentoring
Before you comeKnow in which specialties + Details of the PLAB exam and the Some deaneries publish handbooks for over-
any training opportunities exist and whether IELTS (International English Language seas doctors, and many have senior doctors
you would be happy to train in those special- Testing System) exam acting as mentors for overseas doctors.
ties, in case entry and progress is difficult in + The Overseas Doctors Training Scheme Newly arrived overseas doctors should con-
your preferred specialty. (use links from the National Advice tact the local deanery for these. Use these
Centres website, above) services sooner rather than later.
When should you plan to come? + The various royal colleges (use the links
Whether it is better to come over immedi- Career guidance
from the GMC website, above)
ately after graduation in another country or Even early on, discuss with training super-
+ See also www.doh.gov.uk/
later is not clear. As part 1 of the PLAB visors or mentors an overall career plan. Your
medicaltrainingintheuk
plan would need to bear in mind the available
Practical points in the first few days opportunities, the limitations imposed by visa
restrictions, the requirements for sitting the
Accommodation royal college exams, and your own life situa-
Overseas doctors often first live in accommo-
tion. If your initial plans do not seem to be the
dation provided by the hospitals that employ
right ones, you need to think of contingency
them. In the short term, this can be conven-
plans as soon as possible.
ient, but the quality can often be poor and it
can be isolating. At some point you may wish
Manoj Kumar consultant in liaison psychiatry
to move out and live in a rented house or St Jamess University Hospital, Leeds LS9 7TF
even own your own place. Colleagues can manojkumar@lineone.net
advise you about the most desirable local
1 Department of Health. Hospital doctors: training for the
areas. If you plan to buy a house, you must be future. The report of the Working Group on Specialist Medi-
aware of the mortgage system and your eli- cal Training. London: DoH, 1993. (The Calman report.)

s168 BMJ CAREERS 16 NOVEMBER 2002

 career focus

The first job

Sonali Bapat gives some advice on how to secure your first NHS post and
the compromises you need to consider

I
am an overseas doctor from India and I partners are in the same specialty (paediat-
came to the United Kingdom for higher rics in my case) it is almost impossible to get
training in paediatrics. I had three years jobs or rotations in the same hospital, and
of paediatric experience back home, an MD doctors should be prepared to have a long
in paediatrics, the first part of the member- distance relationship or marriage for the first
ship of the Royal College of Paediatrics and six to 12 months at least.
Child Health (RCPCH), and four publica-
tions in peer reviewed journals. In spite of No interview skills
this, it took me six months to find my first I knew nothing about interview skills when I
training job as a senior house officer in the started. Many interviews have scenario ques-
UK. This was probably because I was too tions about common emergencies encoun-
choosy, applying only to university or teach- tered in the UK. I had not done a life support
ing hospitals and refusing locum jobs. Here course before my first job and often lost out
is my story. to colleagues who had done one.
A candidate's knowledge about audits,
clinical governance, evidence based medi-
International paediatric training scheme
I was sponsored by the RCPCH for their cine, and so on is often tested at interviews
international paediatric training scheme and I did not have in depth knowledge of
(which is similar to the overseas doctors these important issues.
best specialty to start in is emergency medi-
training scheme). This meant I was eligible A different story cine. It is the least popular specialty and
for limited registration with exemption from Things might have been different if I had locums and training posts are usually easily
the Professional and Linguistic Assessment been on an induction course to be oriented available. The next best specialty would be
Board (PLAB) test. It had placed me under in the NHS and learn more about interview psychiatry.
specialty restriction for paediatrics and also techniques. Some deaneries publish competition
restriction on locum jobs (less than three It also might have been different if I had
months duration). ratios (number of applicants per specialist
opted for a different specialty because pae-
registrar post) for each specialty, which is a
diatrics is one of the more competitive
Wrong time good indicator of how competitive the
specialties.
I arrived in the UK at the wrong time specialty is.1
(November) and I didn't start applying for Seniority levelOverseas doctors first jobs
jobs until January. Thus I lost all opportuni- will usually be on the lowest rung of the
Special note
ties for the February session and was eligible training ladder, irrespective of the qualifica-
only for the forthcoming August session. It is Overseas candidates are barred from tions or experience gained in their home
advisable for overseas doctors to come to the taking up unrecognised jobs or jobs countries. In general medicine or surgery,
UK and start applying at least three months allotted for vocational training or you often have to begin as a house officer and
before the February or August sessions general practice. PLAB candidates can for other specialties it would be as a senior
because most training jobs begin in the first take up recognised locum posts in any house officer.
week of these months. specialty, while doctors on the overseas Type of hospitalA district general hospital
doctors training scheme need an is ideal for the first job. District general hos-
approved three to six month training pitals tend to give more practical experience,
Limitations on locum jobs
Owing to time restriction on locum jobs, I job in their own specialty. be busier, have fewer senior staff per house
could not take up any short term locums officer, and a more general and representa-
(one to two months) that were offered to me tive case mix.
by the hospitals where I did my clinical So how did my story end? Overseas doctors often aim for teaching
attachments. I learnt about interview techniques by trial hospitals because they are the tertiary refer-
and error, compromised on the type of hos- ral hospitals. They see more clinically inter-
Selective about hospitals and area pital and region (taking a job five and a half esting cases, but there are more doctors on
I was extremely selective about the type of hours away from my husband), and am now each firm competing for training.
hospital (preferring only university and working as a senior house officer in paediat-
teaching hospitals) and the region where I rics in Wales.
Geographical location
applied, preferring hospitals in the south Some general advice Bigger cities tend to be more expensive and
east and London (to be closer to hospitals Here is some general advice and points to accommodation may not always be available,
where my husband worked). When both consider based on my own experience and especially for families. Overseas doctors with
that of other overseas doctors I have come families often have the additional expense of
into contact with. renting family accommodation outside the
Tips for getting your first job hospital.
Flexibility
+ Start applying in October or April for Overseas doctors have to be very flexible and
February or August jobs persistent to find a training post to meet their And finally . . .
+ Concentrate on district hospitals needs. Careful planning can save time.
rather than university ones Doctors must be prepared to compromise
+ Dont restrict yourself to a city if necessary in their preference of specialty, Sonali Bapat senior house officer in paediatrics,
+ Attend an induction course Gwent
seniority, type of hospital, or geographical sonalibapat@yahoo.com
+ Do a clinical attachment location.
+ Learn about interview skills SpecialtyIt is easier to find jobs in some 1 Whitehouse A. National competition ratios should be
+ Do a life support course specialties and better to avoid others until
available for all HST applicants. BMJ 2002;325(sup-
pl):S55.
you gain some experience in the NHS. The http://bmj.com/cgi/content/full/325/7360/S55

BMJ CAREERS 16 NOVEMBER 2002 s169

career focus

The staff grade dilemma A view from human resources

Many overseas doctors take up a post as a staff grade doctor. Does this lead I have spent 30 years in the NHS so I
to better things or is it a journey into a career cul de sac? Sabina Dosani have been around long enough to
remember all the previous failed
talks to three post holders and John Adsett gives his view attempts at medical workforce planning.
The expansion in the number of staff

D
r Nat Lawson was one of the first staff and describes her job as fitting in well with
grade physicians in southeast Eng- family commitments. Her consultants have grade posts is the latest.
land. He works in care of the elderly at encouraged continuing professional devel- Over the past few years the staff grade
Pembury Hospital, Tunbridge Wells. He says opment (CPD) and she is pleased to have has come in for criticism from managers
that he is often overworked owing to staff accrued all the necessary CPD points for the and doctors alike: managers because the
shortages: There are three staff grade doc- Royal College of Pathologists folder. structure of the grade does not readily
tors here. There ought to be four but they Other staff grade doctors, including fit with the service needs that managers
cant get a fourth person. Dr Lawson, lack protected time for CPD. He need to cover; doctors because it is seen
His clinical role is not clearly defined and says: I try to go to meetings to stay up to date by many as the forgotten grade.
has expanded over his decade in post. I do when I can but it is difficult for them to find Trainees have a new contract and pay
the work of a whole team: house officer, sen- locums when I go off. He continues: I have structure and consultants may soon
ior house officer (SHO), and specialist regis- never had any study leave because nobody have both. Staff grade doctors perceive
trar; I do all of it. In clinics, because they would cover my ward work. I used to go to that they have nothing.
havent replaced the consultant, I see the new regular hypertension updates but I dont feel In my view, doctors have a wrong
patients that he would have seen. Ive agreed comfortable leaving the ward without some- opinion of the staff grade. My own trust
to do that and Im not complaining. That one to cover me. is independently acknowledged to be a
wasnt the agreement initially and feels like Unlike Dr Lawson, Dr Swallow feels that good employer to this group of staff, but
too much work to me. she is doing one doctors work rather than a it still has difficulties in recruiting the
The new deal has been a bad deal for whole teams and says: There is consultant right quality and numbers of doctors.
Dr Lawson: The SHOs all get protected support available 99.99% of the time. She We have many staff grade doctors who
sleep but there are no bleep-free periods for explains several advantages available to her are excellent clinicians prepared to work
me. When the SHOs were overworked, as a staff grade: I get to do clinical work flexibly for the benefit of the service to
people helped to reduce their workload, but which I enjoy, but I don't have to fight my patients. At the moment the
Ive ended up doing their work on top of my corner or get involved with a lot of politics. international recruitment drive is for
other work. But she recognises that it might not be for GPs and consultants, but perhaps that
Dr Lawson is surprised when asked about everyone: I wouldnt do a staff grade job if I could extend to staff grades.
consultant supervision: I dont get any. The wanted to be a consultant. It wouldnt suit a There is no clear career structure to
consultants do come round to see their person who wants to be in charge. which this group of staff can aspire,
patients but they are pleased with my man- although the optional points scheme is a
agement decisions. My decisions are good My future will be just way of rewarding clinical excellence
and no consultant changes them. Im not a the same in this job among staff grade doctors at the local
house officer or SHO who will be phoning discretion of employers.
the consultant every five minutes. I supervise until I retire unless
The solution? If I knew that I would
SHOs when they are new. I know what to do. they change the bottle it, sell it, and retire on the
I dont think there have been any mistakes.
Interestingly, Dr Lawson believes staff
system again and give proceeds.
grade doctors offer patients more: I think me more work to do
staff grade doctors are more devoted to our John Adsett head of personnel at Basildon and
Dr Lawsons view is considerably bleaker: Thurrock General Hospitals NHS Trust and
patients than other doctors as we are not National Secretary of the Association of
I think my contract is until I retire. My future
always moving here and there. We do as Healthcare Human Resource Management
will be just the same in this job until I retire
much as possible and we stay late to get it all The views expressed here are personal and
unless they change the system again and give
done. Most other doctors would be off home should not be taken to represent those of any
me more work to do.
but we are more committed. organisation.
Dr Koravangattu Valsraj is a staff grade
Dr Susanna Swallow is a staff grade doctor
psychiatrist working with the home treatment
in clinical haematology at Rotherham Gen-
team in South London and Maudsley NHS
eral Hospital. Her job was converted from Dr Valsraj doesnt consider this a job for
Trust. Like many overseas doctors, he found
clinical assistant to staff grade two years ago. life. The job works well for me because every-
himself with no option but to take a staff grade
She works four and a half sessions per week one around me knows this is a stopgap. He
job. He explains: Home Office regulations
are very strict and they only allow overseas may have hit the concrete ceiling but is being
doctors to work as an SHO for four years. My helped out and up. Im being supported to
visa could not be extended unless the post- study for my part two exams and as soon as I
graduate dean approved. Despite support pass Ill move on to higher specialist training. I
from many consultants, clinical tutor, medical have one session of protected time to study
director, and director of postgraduate educa- and my post meets the colleges requirements
tion, bureaucracy worked against me and I for educational approval. Theyll give me time
was forced to become a staff grade doctor. off before the exam as well.
Like Dr Swallow, he finds some aspects of Although he enjoys his job, he would be
the staff grade role advantageous: I enjoy the unhappy if it became more than a stepping
clinical work; I work with an excellent team in stone. Im sure he is not alone in saying:
an innovative area and have learned a lot Overseas doctors can get stuck in staff grade
about setting up a new service from scratch in jobs due to Home Office restrictions.
line with the national service framework. I
wouldn't have got that out of an SHO job Sabina Dosani portfolio doctor
because this job isnt approved by the Royal London
College of Psychiatrists for SHO training. s.dosani@medix.uk.com

s170 BMJ CAREERS 16 NOVEMBER 2002

 career focus

How to enjoy your training as an overseas doctor

Kallur Suresh gives some advice

I
came to the United Kingdom in 1996 as Alternatively, you can accept the inevita-
an overseas doctor so that I could obtain bility of the problems and deal with your own
higher training in psychiatry. I had previ- reactions to them (emotion focused cop-
ously trained for nearly four years and had ing). This includes expressing emotions,
some research experience in psychiatry in seeing the problem in a positive light and
my own country. I have seen several overseas recognising that it has led to some good, or
doctors come to the UK for medical training, refusing to think about the problemin
and many of them have found it hard to other words, avoidance.1 You can choose
adjust to their new environment, at least in which strategy you want to use in each situa-
the initial stages. tion you face, although in most cases the first
The systems for supporting overseas doc- approach is generally better than the second.
tors are well developed in some regions but I have illustrated these strategies in the Find support
examples in the box. Friends
are all but non-existent in others. More often
than not, it is left to your own initiative to solve You need support at various levels during
your career. An informal network of friends
the problems you face as an overseas doctor. Tips to maintain your mental from your home country who have gone
I have been through the process myself,
and if I had to do it all over again, I would do it
health through similar difficulties should be the first
differently. I have been an informal adviser to + Give equal attention to life outside contact for most overseas doctors.
overseas doctors when they have found things work. Get the work-life balance right
difficult. I have written this article in the hope + Learn to manage changeboth Junior doctors committee
that it will help overseas doctors enjoy their professional and personal Most hospitals have a junior hospital doc-
training more. Obviously, there is more than + Value yourself and your previous tors committee which meets regularly and
one correct way of doing things, but other experience and training overseas discusses problems facing trainees.
overseas doctors may find my advice useful. + Be open with your feelings. Deal with
negative emotions by recognising Educational supervisor
Your educational supervisor can support
Ways of coping them, sharing them with another
you during your attachment with him or her.
Generally, there are two ways of coping with person, and using positive coping
Many places have a mentor scheme, in
difficult situations. You can face the difficul- strategies
which an overseas trainee is attached to a
ties head on and try to change things for the + Take steps to reduce your loneliness
named person who is available for guidance
better (problem solving approach). This + Take time out to relax
and support.
entails: listing and defining the problems; + Do something you enjoy that is
brainstorming for practical solutions for totally unrelated to medicine
Look after yourself
each problem; and then trying out one of the + Get involved in things at work you
The most important tool you need to do
courses of action that seems most likely to are really interested in
your job well is you. It is important to pay
succeed; and reviewing the results to see how + Develop your own personalised
attention to yourself and see whether you
well the original problem has been resolved. strategies to deal with stress
can do something that will enhance the qual-
If it has not been resolved, you try another + If you dont know, ask for help.
ity of your life. Your psychological health
course of action. affects your performance at work and your
relationships.
The problem: English language difficulties Allow time
Examples of problem solving approach strategies Adjustment to a new society, culture, and
+ Specify the problem: spoken, written, or both? system of working is often a lifelong process.
+ List resources: courses, books, CD-ROM, web based teaching. Seek others help So allow yourself and your family plenty of
+ Choose one course of action: attend a spoken English course time (often many years) to do so. Some
+ Re-evaluate your language skills to test for improvements things will always be difficult, no matter how
+ Go back to the beginning for the next problem long you spend trying to adjust to them.
Examples of emotion focused coping strategies Chances are, they are difficult for the indig-
+ I shall not think about it enous population as well.
+ I accept I cant or dont want to do anything about it
+ I accept that my language will always be somewhat different Kallur Suresh overseas doctor and specialist
registrar
+ I will try not to be upset about it Department of Psychological Medicine,
St Bartholomews Hospital, London EC1A 7BE
The problem: Difficult consultant Kallur_suresh68@hotmail.com
Examples of problem solving approach strategies Further information
+ What is the difficulty? Bullying, lack of supervision, or not supportive? Department of Health. Medical training in the
+ Discuss openly with the consultant if possible United Kingdom: A guide for international graduates.
+ Get peer support from junior doctors committee London: Department of Health, 2000. (www.
doh.gov.uk/medicaltrainingintheuk/
+ Bring it to the attention of your clinical tutor or clinical or medical director
internationalgraduates.htm).
+ Consider feedback during college or deanery approval visit to your scheme
Doctors.net (www.doctors.net.uk) This website
Examples of emotion focused coping strategies runs discussion forums through which you can
+ I am here for only six months, so I cant do anything about it obtain informal advice from other doctors.
+ I have worked for worse people
+ I will miss the meeting this morning in which I am likely to bump into him or her 1 Gelder M, Gath D, Mayou R, Cowen P. Reactions to
stressful experiences and minor affective disorders. In:
+ He or she is not so bad after all because I have learnt some new things Oxford Textbook of Psychiatry. 3rd ed. Oxford: Oxford
University Press, 1996: 134-59.

BMJ CAREERS 16 NOVEMBER 2002 s171

career focus

Top tips for getting through the system and

having a successful career in the UK
Overseas doctors coming to work in Britain need as much practical advice as
they can get. Here are some tipsfrom overseas doctors already working here

A
few months ago, we asked overseas doc- Adjust to the weatherResign yourself to
tors to tell us what their top tips would the fact that there are just two seasons in
be to help other overseas doctors Britain, mild winter and winter, and dress
progress in the United Kingdom. Here is a accordingly.
selection of the responses we received.
Getting ahead
Come early Work hard and excel in your workBe pre-
Once you have decided to come to the pared to learn about the new standards and
United Kingdom, dont waste valuable time expectations in all areas of work and life. Be
in gathering postgraduate or service experi- realistic, flexible, and willing to learn and against local candidates who are equally
ence in your own countrythe sooner you adapt to new systems and different commu- qualified, overseas doctors should be able to
make the move, the better. The reasons for nication etiquettes between professional show they are better.
groups, and patient and carer groups. If pos- Aim highDont be afraid to state that you
this are twofold. Professionally, you are not
sible, attend local postgraduate meetings, wish to progress to the top.
too far down a particular career path and so
obtain clinical attachments, and enquire
are in a better position to choose a specialty Work your guts outThere is no substitute
about the types of training and supervision
that offers the best chance of progress at that for hard work. Look for reasons for failure,
available. Prepare well for interviews and
time. Socially, you are more likely to be free not for excuses. Appraise yourself regularly
examinations, and use all opportunities to
of the responsibilities that come with age and work towards your desired goal. Do not leave and thoroughly.
so are more ready to accept, for example, an things to chance. Become adept at networkingThis is particu-
academic position that may be good for your larly important with the consultants or GPs
career but often brings a poorer salary. you work for. A helping hand from someone
more senior could make all the difference.
Settling in
Learn to networkComing to a new coun- Sticking with it
try, with its different language, cultural atti- Persevere and persistLife is competitive
tudes, and values in life and work, demands and tough, so learn to be patient. As a mem-
that to get on you have to seriously orient ber of a minority group you have to work
yourself to your new environment. Establish through subtle discrimination and be in
contact with local general or specialist hospi- some ways at a disadvantage. Overall, the
tal tutors, overseas doctors associations, and system is probably still fair despite its short-
specialist associations. Using the available comings. It might just take a few years longer
mentoring schemes would be a good start. to get where you want to go.
Learn to speak English like a nativeIt is Stay focusedNot earning much in the
initially very difficult to learn to speak slowly, early days can be a blow to your ego, as can
clearly, and without an accent (especially being a stranger in a new health service.
while speaking to the locals and to col- Often friends and family are far away, and
leagues). You have to make a conscious effort Do audits and presentations, and get loneliness can creep in, making you wonder
to slow down the speed you speak at. Initially, publishedFor various reasons many over- why you are here. Keep your goal in mind,
you are very aware of your accent and the seas doctors will not have opportunities in and any obstacles will fade into insignifi-
extra effort you need to make to be under- their own country to do audits and presenta- cance.
stood. But, with time, that effort and aware- tions or publish articles. But it is an impor- Rely on inner strengthIt is crucial not to let
ness disappears. tant component in the shortlisting process in repeated stumbling blocks blur your focus.
Join the Medical Defence Union or BMA Britain. So the sooner you can do this, the Rely on your inner strengthremember,
These are good at offering advice if you run better. Academic success seems to impress tough times dont last; tough people do.
into problems. everyone. Developing an academic interest
and displaying your presentation skills early Examinations
on in your career usually go a long way. Get the exams over with early onOnly then
Finally, for extra impact, make sure you pub- will you have the time to involve yourself in
lish in a journal that is indexed on PubMed. academic activities and strengthen your CV.
Do something moreEveryone who applies This will also help you to channel your efforts
for a job will have passed the PLAB (Profes- towards building up useful preregistrar
sional Linguistic Assessment Board) exam experience in your chosen field.
and also have other higher qualifications. But Get your exams at the right timeThis is
to get shortlisted and get the job, do some- essential. Do not sit back and relax during
thing more than othersfor example, com- a rotation. Membership exams can take
puter and management courses. This may several attempts. However, a long gap
make you stand out from the crowd. between getting your membership and
Be an exceptional trainee: produce something applying for higher specialty training is also
extraMerit is rewarded irrespective of the not favourable.
origins of the trainee. In the current system Know the examTry to understand the
of competitive entry, you have to show that type and level of knowledge that is being
you are willing to put in just that little bit asked of you. Identify the frequently asked
extra. If overseas doctors are competing topics and study them in depth. Remember

s172 BMJ CAREERS 16 NOVEMBER 2002

 career focus

that the disease spectrum and management Try to get your first job in a remote district
may be different from what you are used to in general hospitalThese jobs may be relatively
your home country. less competitive as such hospitals are usually
Plan aheadDecide how much time you extremely busy and opportunities for social
will need. Make a realistic daily timetable for activities may be limited. You are, however,
yourself two to three months before, taking likely to emerge as a better doctor with all
into account on-call shifts and days off. that hands on experience with unselected
Remember to book relevant courses early emergencies. Also concentrate on six month
and to discuss study leave arrangements with jobs rather than on rotations, which can be
your colleagues well in advance. Make a list reserved for later.
of the books you will need. Find out which Be prepared to moveBe prepared to move
are available in the library, which you can anywhere in the United Kingdom where you
borrow from friends, and which are worth think the best job is available, regardless of
buying. where your friends are working. You are
Believe in yourselfYou will have spent here for the best training, and relocation is
months getting ready for the exam. Tell your- one of the sacrifices you should be prepared
self you can do it. Chances are you are at least to make.
technicians, and medical secretaries. Help
as good as the rest.
and advice from these sources will assist
greatly in cutting down your workload.
Finding jobs (and the right specialty) Socialise with your colleaguesSocialising in
Define successful career clearlyWhat do
the pub is very much part of British culture.
you wish your career end point in the United
Sharing a drink or two with your colleagues
Kingdom to be? Take copious appropriate
after work is considered normal. Not doing
advice. If you cannot be a big fish in a big
so is not considered abnormal, but you risk
pond, would you accept being a big fish in a
getting labelled aloof and unfriendly.
small pond, or a small fish in a big pond?
IntegrateIt takes time to be accepted, but
In other words, if you are unable to achieve
if you are seen to be one of the team, there
your desired goal, what would you be pre-
are enough fair doctors in the British medi-
pared to settle for?
cal system who will make sure you get on.
Be decisiveWhen arriving in Britain, most
Be prepared for ups and downsRemember
overseas doctors intend to go back home
that you are part of a team. When you speak to
eventually but, when it is time to return, most
your consultants, be honest with them. Never
want to stay. In the process, many spend a few
lie. The bleep is something of a curse and a
valuable years in painful confusion and end
up professionally dissatisfied. It is important blessing. Always try to answer it promptly, but
to realise that jobs that are good for those Wait for the right jobIts a good idea to do if you are late in answering it, explain why.
who want to stay may not necessarily be so a clinical attachment with a professor rather Get to know the pharmacyWhen you start
for those wishing to go back. You must than go straight to being a first on-call work, get to know the hospital pharmacy
choose early on what is good for you and you senior house officer (SHO). department. Pharmacists have a wealth of
can do that only if you have your intentions Enhance your CVYour CV should always knowledge on drug pharmacology, route of
clear from the beginning. show that you are making steady progress in administration, adverse events, interactions.
Keep an open mind about specialisingDont your career. Do not accept another six They operate an on-call system, which may
have unrealistic expectations about which month SHO post just because it is in the be useful when you are working nights.
specialty to work in. It may be easier, for same hospital or area. You have only four Enjoy talking with your patientsMost
example, to get ahead in anaesthesia or psy- years to prove that you are suitable for entry people love to chat, and it is useful to
chiatry than in surgery. Most overseas doc- at the specialist registrar (SpR) grade. Stag- know about football teams or television
tors struggle because their chosen field is nating at one level is not looked on favour- programmes.
competitive, and they may not realise this ably, and you should seek jobs that show
until they have started applying for jobs. commitment to your chosen specialty, or Rhona MacDonald editor, Career focus
Also, remember to choose a specialty that is alternatively work as a more senior SHO or BMJ
under-represented in your own country. in locum training posts while you look for
Do a clinical attachmentDoing clinical Many thanks to the following contributors:
that coveted training number. Thakor Mistry, consultant psychiatrist, Hallam
attachments and even a UK degree (such as Attend interview skills coursesOften over- Street Hospital, West Bromwich; N Vishwanath,
an MSc or Diploma) related to the profession seas doctors get shortlisted but do not get Manchester; Seemit Dhage, SHO, Kings Mill
and field of your interest may help your job through the interview. Attending courses on Centre, Mansfield; Vishal Kapoor, SHO, Barnsley
prospects dramatically. interview skills or having mock interviews District General Hospital; Faiyaz Mohammed,
may help you overcome this problem. SpR in general medicine/gastroenterology,
Royal Oldham Hospital; B Nirmal Kumar, con-
Good communication skills are an assetAt
sultant otolaryngologist/head and neck surgeon,
an interview, the panel must feel comfortable Wrightington, Wigan and Leigh NHS Trust,
with you and believe that you are someone Wigan; Ayesha Rahman, SpR in radiology, Hull
who will communicate well with patients and Royal Infirmary; Inamul Hai, staff grade, Taunton
staff. and Somerset Hospital; Karthik Maruthachalam,
SHO in colorectal surgery, Ormskirk Hospital;
When you are in your job N Sumanth, SHO in paediatrics, North Hamp-
Be politeBe polite rather than abrupt shire Hospitals NHS Trust, Basingstoke; R Kap-
por, SpR in paediatrics, Princess Alexandra
when dealing with hospital staff, and patients
Hospital, Harlow; V Khanduja, SpR in trauma
and their relatives. This makes work a com- and orthopaedics, North Thames Rotation,
fortable and enjoyable experience. London; Vibhash Mishra, staff grade urologist,
Be friendlyLearn quickly how to develop Wexham Park Hospital, Slough; Nutan Mishra,
a friendly working rapport with other col- SpR in obstetrics and gynaecology, Frimley Park
leagues, nursing staff, ward clerks, laboratory Hospital, Frimley.

BMJ CAREERS 16 NOVEMBER 2002 s173