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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’.

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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