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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)

  • @1:15, as far as I can understand there is no such issues with examinations in other specialities, its about the CSA.
    And about your comment re drs drawn here from USA to UK, I have yet to come across a dr from USA in a UK specialist training scheme.

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  • Why do doctors come here? Well, the GMC recruits doctors in the developing world. For example, when in 2003 there were 12,000 drs registred by the GMC by lowering the PLAB standards artificially. Drs come here for many reasons. If you do not know any one reason, go to an IMG and ask him.
    Education England is recruiting 75 doctors next month from New Delhi without even asking the drs to take the PLAB exam.
    Once they come here, the GMC,Deaneries and the EE will jump on every silly issue which happens to be connected to these doctors making their lives difficult.
    But some people keep asking 'Why do they put up with this if they can go away'.
    Not easy to just leave and walk away.
    When refugees escape a country, and try to make a living in some other country, every one wonders why did they not stay put and stand up against mistreatment in their place instead of running away.
    At the end of the day, many people will go, but not every one has the same thinking of running away from where problems are. Atleast glad that not the entire GP and hospital workforce ran away already to better pastures.

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  • Thank you. As we are not a training practice nor are we recruiting Drs because of where I work all my IMG colleagues locally are well established and I have in the past discussed their reasons to move half the way around the world. My reason for asking on here is to see if there were any more specific a reason why IMG would come to the UK currently given the opinions stated on the quality of training and medical education here. As I do not work with newer IMGs and many identify themselves as such in these and other posts I hoped to gain a bit more of an insight from replies on here. It seems there is no obvious pull to the UK beyond those you would predict so it looks currently as if the UK will become less attractive to IMGs as things currently stand.

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  • Study commissioned and interpreted with help of directions from the top brass, who are adept in Public Relations. To deflect attention from their deficits, they commission studies on 'deficiencies' of IMG doctors. Conclusion? Half the doctors in the UK are not safe.
    Public do not believe it. So scare them into believing.
    Talk about 'Patient safety', 'communication skills' and 'language skills'. And finally recruit more drs from the New Delhi to fill gaps in the rotas.

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  • @Dr Caldwell
    Interesting to ask why img come to UK. Answer are many but in nut shell they come for better life and training. Many want to go back however they get stuck at some point in training so either become specialty docs (an exploitation that only happens in uk and australia) and cant go back because of lack to training to consultant grade. Many become GP for persumably for better life and they cant go back because in south asian countries one can become gp after graduation andhouse job. If IMG get full training to cct in hospital specialties believe me many will go back. You cant imagine the life of consultant trained in west in these countries. Hope this explains.

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  • Una Coales

    Thomas I found this. It seems that the NHS does active recruitment drives in India to plug junior hospital jobs when the NHS is in a shortage crisis. Seems illogical then for this study to bash IMGs when the NHS is desperately short of GPs?

    NHS IMG GPs are very demoralised over this study and many are looking towards emigrating to Australia along with their UK counterparts.

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  • Una Coales

    Another government recruitment drive from India to help A&E doctor shortages. Why should India help the NHS after all the recent bashing?

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  • Una Coales

    23% of NHS GPs are foreign graduates. We are in a national GP shortage crisis compounded by an exit actor CSA exam that fails 64% of IMGs and 4-6 times more British BMEs than white Brits. This recent study authored by 2 researchers who have been commissioned by the RCGP in the past also, so not entirely independent, may undermine the confidence of NHS IMG GPs working flat out to keep their surgeries open at little to no partner drawings.

    I once wrote and advised that the RCGP must not be seen to be unwittingly aiding government and contributing to the demise of general practice.

    Without GPs and with constant government cuts to GP funding, GP surgeries will close and patients will not get semiprivate healthcare but solely private; Government has not come up with any provision as of yet as to how the poor or elderly will access healthcare once the NHS closes.

    At a time when our profession needs unity, feeding media to bash IMGs, is in my opinion, contributing to the demise of NHS general practice.

    Remember private GPs and consultants belong to another organisation, the Independent Doctors Federation, who, in my opinion, are doing a great job lobbying against private health insurance cuts to reimbursements and high MDO indemnity charges.

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  • The meme is that doctors are getting away with something and need constant training, watching and regulating. With this in mind, it’s almost a reflex for policy makers to pile on the regulations. Regulating the physician is an easy sell because it is a fantasy—a Freudian fever dream—the wish to diminish, punish and control a disappointing parent, give him a report card, and tell him to wash his hands.
    Just this rule is applied more strictly to certain groups
    The above is an opinion which may or may not be correct and any relation to anyone anything is merely coincidental

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  • Gravy trains of £90 million pounds to the GMC every year collected from doctors on compulsion and £many millions to the Colleges through exams, memberships and other avenues are difficult to be justified, other than by constant scare-mongering and demonisation of the doctors.
    When some one questions their deficits and asks them Qs, they commission compromised research projects and get them published by hand twisting and then utilise the connections in the press, which is anti-foreign doctor.
    It's all money stupid-My quote.

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