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A faulty production line

International graduates should face higher bar to work in the UK, finds GMC-commissioned research

International medical graduates (IMGs) could face a higher bar to work in the UK after GMC-commissioned research concluded the assessment that allows them to practise medicine in this country may be too lenient.

The research – published today in the BMJ – found that graduates of the Professional and Linguistics Assessment (PLAB) had poorer clinical knowledge and skills than UK graduates on average, according to their performance in the MRCGP exam.

Overall, PLAB performance correlated well with performance in the MRCGP, but on average PLAB graduates’ marks were one standard deviation lower than UK graduates’ marks on the applied knowledge test (AKT), and 1.82 standard deviations lower on the clinical skills assessment (CSA).

In response, the RCGP recommended the GMC review the PLAB ‘as a matter of urgency’ saying it was ‘in the interests of patient safety’.

The PLAB test is designed to ensure that non-EU trained doctors demonstrate the same level of medical knowledge and clinical skills as UK graduates who have completed their first foundation training year (F1).

It is required for IMGs to work in the UK, but the researchers concluded that the standard of the test had been ‘set too low’ compared with the standard of UK-trained graduates.

The researchers – led by Professor Ian McManus, professor of psychology and medical education at University College London, and commissioned by the GMC – compared 4,548 PLAB graduate first attempts at the AKT or CSA parts of the MRCGP exam with that of 18,129 UK graduate first attempts over the same period. They also compared PLAB graduates performance with that of UK graduates on the MRCP exam.

They estimated that raising the pass mark for PLAB part one by around 35 marks and that for PLAB part two by 10 marks above the current standard would lead to equivalent performance between IMG and UK graduates on the MRCGP exam.

They acknowledged that this would have ‘implications for the health service workforce’ by barring many more doctors from working in the UK, but said their data ‘suggest that the standard for PLAB has in recent years been set too low if equivalent progression by PLAB graduates to UK graduates is expected and required’.

They concluded: ‘Equivalent performance in MRCP(UK) and MRCGP would occur if the pass marks of PLAB1 and PLAB2 were raised considerably, but that would reduce the pass rate, with implications for medical workforce planning.’

Meanwhile, a second study also published in BMJ today, concluded that higher pass marks on the PLAB and higher standards of English language competency – or even a completely different testing system – were needed to even out postgraduate performance between IMGs and UK graduates.

GMC chief executive Niall Dickson said ‘This review, along with our decision to increase the score we require in our assessment of English language skills, will help us ensure that high standards of practice are maintained. This is vital not only for patient safety but also for maintaining public confidence in the standards of care in the UK.

‘This is a complex area, but this research does raise important questions – not only for us as a regulator, but for UK governments and for the profession too. All parties need to work together to address this, not just because it’s the right thing to do for the individuals, but because of its implications for the healthcare workforce and for the standard of care provided to patients by all doctors, regardless of where they qualified.’

RCGP chair Dr Maureen Baker welcomed the ‘important research’ and urged the GMC to take action.

She said: ‘The conclusion that the average knowledge and skills of those currently passing PLAB are below those of UK graduates and that the PLAB standards therefore need to be raised will then have a positive effect on IMGs since those who meet higher PLAB standards are far more likely to pass the MRCP(UK) and MRCGP.

‘In the interests of patient safety and fairness to international medical graduates, we recommend that the current PLAB standard setting process is reviewed as a matter of urgency.’

The research looks set to reignite the long-running row over the differences in pass rates for the MRCGP between white and non-white medical graduates.

These tensions came to a head last week at a judicial review brought by the British Association of Physicians of Indian Origin (BAPIO). In his final judgment, Mr Justice Mitting found the college had not directly discriminated against any candidates, but said that ‘the time has come’ for the RCGP to address the differentials in the pass rates.

Dr Umesh Prabhu, vice-chair of the British International Doctors’ Association, said: ‘There is no evidence to suggest that those doctors who failed MRCGP exam are unsafe doctors or provide poor-quality care. Also, currently the UK doesn’t even test EU doctors’ competency, so how does this fit in with making the NHS safer and better for patients?’

Dr Krishna Kasaraneni, chair of the GPC trainees subcommittee and the BMA equality and diversity committee, said: ‘As highlighted by both these papers, the question still remains why significant differences exist between doctors of different ethnic groups who trained in the UK.’

BMJ 2014; available online 17 April

Readers' comments (46)

  • Why not try something similar to USMLE ??
    USMLE is taken by USMGs and IMGs before they commence specialist training, so there is level playing field.

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  • The cohort of IMGs in US is similar to UK. And medical training in US is comparable to UK. This link to USMLE passrate for IMGs is interesting !

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  • In continuation to above, just did some more searching, as per USMLE website pass percentage for USMGs is in around 90s and for IMGs it's in around 80s. This is more acceptable and fair.

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  • Una Coales

    'One explanation for the GMC's review of the PLAB examination, reported here last week, is offered in Doctor(p11, 10/6/99). The newspaper claims that when the GMC's Professional and Linguistic Assessment Board exam for doctors was tested on a sample of 50 UK graduates last year only two passed. This is an embarrassing result whatever way you look at it, though it is claimed that the sample was not representative. According to the story, the results were then withheld from the council's deliberations last month for fear it would lead to claims that the test was unfair to overseas doctors.' Enough said.

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  • @3:21
    The USMLE is a very academic exam, with candidates expected to know a lot more medical detail than we are expected in the UK. It is more like the old style UK medical exams with a greater emphasis on pathology, anatomy, physiology etc.

    The UK system has evolved and now looks at wider skills more in keeping with the actual practice of medicine. It is probably less that the future professors will get the highest in exams at this stage; but is more likely to pick out those who are terrible at interacting with patients.

    In many countries outside the UK, their medical education is more in keeping with the US system/ USMLE exam - with a bigger emphasis on academia. Certainly for India entrance to medical school is extremely academically challenging. It is fairly unsurprising that their pass rates are less different for a more academic exam.

    I think it is fair to say that a cohort of random UK graduates, on graduation day (without extra preparation) would do less well at USMLE than a cohort of South Asian graduates.

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  • Una Coales

    Why bash IMGs? They sat and passed PLAB, a UK exam that only 2/50 UK grads could pass in 1999. Can we instead focus on the EU doctors from the following countries who use the EU trade loophole to get out of sitting any UK exam, PLAB or MRCGP.

    Member states of the EU
    (year of entry)
    Austria (1995)
    Belgium (1952)
    Bulgaria (2007)
    Croatia (2013)
    Cyprus (2004)
    Czech Republic (2004)
    Denmark (1973)
    Estonia (2004)
    Finland (1995)
    France (1952)
    Germany (1952)
    Greece (1981)
    Hungary (2004)
    Ireland (1973)
    Italy (1952)
    Latvia (2004)
    Lithuania (2004)
    Luxembourg (1952)
    Malta (2004)
    Netherlands (1952)
    Poland (2004)
    Portugal (1986)
    Romania (2007)
    Slovakia (2004)
    Slovenia (2004)
    Spain (1986)
    Sweden (1995)
    United Kingdom (1973)
    On the road to EU membership
    Candidate countries
    The former Yugoslav Republic of Macedonia
    Potential candidates
    Bosnia and Herzegovina
    * This designation is without prejudice to positions on status, and is in line with UNSCR 1244/99 and the ICJ Opinion on the Kosovo declaration of independence
    EU around the globe

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  • ‘Equivalent performance in MRCP(UK) and MRCGP would occur if the pass marks of PLAB1 and PLAB2 were raised considerably, but that would reduce the pass rate, with implications for medical workforce planning.’
    Medical workforce planning guides the pass marks of the PLAB exam. We knew this all along. in the early 2000s the pass rate was very high and now its only 35%. So how come an exam which is supposed to test doctors skills used for work force planning? Enquiring minds wants to know.

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  • @5.35 USMLE step 2 CS involves OSCEs similar to PLAB 2 and MRCGP CSA. Learning medicine without understanding anatomy, physiology, pathology, microbiology etc is perhaps a not a very evolved way .

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  • Una Coales

    All this fuss over PLAB that tests and allows approx 2,700 IMGs join the depleted NHS workforce each year.

    the number of candidates who took PLAB Part 1 and passed each year
    ,with the pass percentage

    PLAB Part 1 1998 -2012
    Candidates Pass Pass%
    1998 3272 908 28
    1999 3605 1211 34
    2000 3438 1631 47
    2001 4680 2826 60
    2002 8305 5095 61
    2003 12500 7825 63
    2004 12584 8004 64
    2005 9117 5630 62
    2006 3979 1842 46
    2007 2506 1002 40
    2008 2493 944 38
    2009 3404 1477 43
    2010 4545 2391 53
    2011 4068 1425 35
    2012 2930 1344 46

    b. the number of candidates who took PLAB Part 2 and passed each year
    ,with the pass percentage.

    Part 2 1998 -2012
    Candidates Pass Pass%
    1998 649 516 80
    1999 1198 1067 89
    2000 1362 1132 83
    2001 2508 2091 83
    2002 3741 2948 79
    2003 6579 5207 79
    2004 8208 6392 78
    2005 8569 6585 77
    2006 2936 2166 74
    2007 1379 1080 78
    2008 1370 938 68
    2009 1847 1284 70
    2010 1636 1168 71
    2011 2637 1835 70
    2012 1735 1182 68

    c. the number of IMGs who registered for the first time as new doctors
    with the GMC for every year since the PLAB was introduced.

    First Registration Year # of Doctors
    1998 4,947
    1999 4,365
    2000 4,644
    2001 4,252
    2002 5,147
    2003 11,996
    2004 6,328
    2005 5,821
    2006 3,159
    2007 2,609
    2008 2,841
    2009 2,589
    2010 2,971
    2011 2,461
    2012 2,727

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  • Vinci Ho

    It is very interesting to read what Nial Dicksionson said on BBC health news:
    Mr Dickson said more needed to be done to help foreign doctors coming into the UK, and to recognise the difficulties they face with different social and cultural attitudes.

    "Doctors are a bit like flowers. We don't just take them up from one garden and plonk them down in another and expect them to thrive," he said.

    "They need to be supported and helped, and I don't think as a country, and I don't think that the NHS or indeed we have done enough to support them when they are coming into this country."

    Mr Dickson also praised foreign doctors who do a "fantastic service" to the NHS.

    But he added that there needed to be a focus on training more doctors in the UK and less of a reliance on those from overseas.

    One wonders the tone might have been different should GMC NOT 'dragged' into the judicial review of CSA examination ?? ( JR certainly has done something !)
    After all , were there figures to study those who passed PLAB and went onto take other colleges' examinations ?Not logical to 'marry' MRCGP exam with PLAB as the former had been questioned so much.......

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