Post Graduation & Specialization in UK
Table of Contents
	National Health Service.		Entery as SHO/FY2/BST.		Foundation Program.
	General Physicians (GPs) & Specialists.		House Job.		After Foundation Program.
	Basic & Specialized Training.		I.E.L.T.S.		Overseas Doctors & Foundation Program.
	Different Grades in UK.		PLAB Examination.		How to Improve Your Chances.
	Pre-Registration House Officer.		Registration.		Grow Your C.V Concept.
	Senior House Officer.		Finding a Job.		Your C.V - As a Student.
	Staff Grade.		Job Situation.		Your C.V - As a House Officer.
	Type I SpR.		Scope for Overseas Doctors.		Your C.V after House Job.
	Type II (FTTA) SpR.		Issues Regarding Finances.		Your CV - after Entering UK.
	Trust Post.		Membership Examinations.		Presenting the CV.
	Locum.		Modernizing Medical Career.		Job Interview.
	Possible Entry Points in NHS.		Integration of Both Systems.		Terms Not Covered.

The National Health Service, or NHS is responsible for providing healthcare to the residents of the UK and training the doctors who work for it. The NHS is organized to maximize the efficiency of health-care delivery. Its structure is somewhat different from the structure of health care in Pakistan or the US.

If you are living in the UK and you get sick, you will go to what is called the General Practitioner, or GP. Every citizen in the UK is entitled to be registered with the GP near his locality. He will be your personal doctor, and whenever you fall ill, you will go to him first. He may diagnose your illness and treat you, or if he feels that your illness requires the expertise of a Specialist, he will refer you to one. The advantage of this system is that when the patient first interacts with his healthcare system, he is managed in a way that maximizes the efficiency of health-care delivery. If the ailment is simple and within the ability of the GP to treat, there will no further need to burden the NHS with the case. Furthermore, after seeing the patient, the GP will, if nothing else, be able to refer the patient to the Specialist that can best treat him. In countries where this system is lacking, the fragmentation of medicine and surgery into so many specialties can make it difficult for the patient to decide which department he should go to seek a cure. The patient for example, may go to a Pulmonologist for his breathlessness while his actual problem is cardiac. At best, such inappropriate visits can simply cause an added burden on the healthcare system and at worst, can cause an incorrect diagnosis.

The reason this distinction is important for our purposes is that overseas doctors who train and work as GPs in the UK may find it difficult to return and practice in their home countries where the healthcare system is not organized to have a well-defined role for such doctors. This consideration must be made before any overseas doctor decides firmly that he wishes to pursue a career as a GP because in the UK, a GP’s skills and professional development is influenced by a network of Specialists he can call on whenever he feels the need.

To train to become a specialist, the doctor must pass through two stages of training. The first stage is called General Professional Training which will probably be known in the future as the Basic  Specialist Training.  This training is imparted during the time spent as an Senior House Officer (which is explained below).  

The second stage is called Higher Specialist Training – which lasts during the time spent as a Specialist Registrar (SpR) (which is explained below.

Thus the doctors in the NHS can be broadly groups into the GPs and the Specialists.

However, the categorization is not that simple. Doctors in the NHS are in “grades” reflecting their position in the hierarchy of the NHS. As doctors get into higher grades, they get paid more, assume greater responsibility and, it must be said, attain greater prestige as well.

The lowest grade is the Pre-Registration House Officer (PRHO). UK graduates enter this grade immediately after graduating from medical college. The term “pre-registration” is applied to this grade because after completing it, the doctors are “fully registered” in the General Medical Council, or GMC of the UK. They are, in other words, registered as doctors. This is similar to the Pakistani system, where an MBBS student is only registered with the PMDC as a Registered Medical Practitioner (RMP) after completing a one year house job. The PRHO lasts for one year after which doctors compete for posts (i.e., jobs) in the Senior House Officer (SHO) grade.

The overwhelming majority of overseas doctors coming to the UK today compete for the SHO posts. There are very few PRHO posts for overseas doctors, so not many get them. This is why most doctors who apply for posts in the UK do so only after they have completed house jobs in their home countries.

SHO posts last for 6 months in a certain specialty. Job opportunities for SHO posts are advertised openly and awarded on a competitive basis.  After finishing one SHO posting, doctors apply for the next, and then the next, and so one until they leave this grade by attaining their Membership of a Royal College - which we will come to shortly. Doctors remain in this grade until they attain their Membership. However it is possible (and this in fact has become a big problem for the NHS) that doctors simply stay in the SHO grade for 8-9 years before getting around to completing their memberships. Indeed, currently there isn’t a built-in mechanism within the NHS structure compelling doctors to attain their membership quickly and leave this grade. Ideally, the doctor should attain his Membership within 3-4 years and move forward, taking on greater responsibilities, and making room for newer doctors in the SHO grade.

The different SHOships are not centrally integrated by any educational body. This makes it difficult (at least to the overseas doctor whose does not have the luxury of rejecting any SHO post he is given) to ensure that the time spent in the SHO grade will follow a well-planned, integrated programme. This is in sharp contrast to the US system where a US resident has a fixed contract with a certain hospital and will continue to work and train there for several years. If he has chosen go into Internal Medicine, he will spend a fixed amount of time in the different subspecialties of Internal Medicine and be transferred from one ward to the next without any interruption of his training.

The reasoning behind limiting the SHO posts to 6 months at a time, with no centrally decided integration between the different SHO posts is to give the doctor the opportunity to sample different specialties. If for example, he wishes to experience Nephrology, he can take a 6-month job in it. If he wants, his next post can be in Psychiatry. By spending 6 months in such posts, he will be able to decide if he wants to pursue that field as a specialist, and even if he doesn’t, the exposure and knowledge learned in that field will add to his body of knowledge and make him a well-rounded doctor.

However this system was designed and set in place decades ago, when competition for SHO posts was not as fierce as it is now. So, while the theory of 6-month SHOships seems fine, the system becomes flawed when the SHOship that a doctor enters is not out of choice, but out of compulsion - caused by today’s difficult job situation. This problem hits overseas doctors the hardest, who are considered for SHO posts only after UK-graduates are accommodated first.

Since there is no link between the first and second SHO post, it is quite possible for you to be exposed to very different specialties during your time as an SHO. One post could be in Cardiology for example and the next in Psychiatry. For the overseas doctor, its a matter of taking what you can get. 

Having said that however, it must be emphasized that the training imparted during the SHOship is quite good. A hard working doctor can benefit immensely and learn a lot during his time as an SHO.  Another important clarification to the above is that not all SHO posts are 6-month contracts. They can be 2-3 year contracts in which planned, integrated rotations are structured into the training. However it is very difficult for overseas graduates to obtain such contracts. The vast majority receive 6-month posts.

During the SHOships, the doctor will study and train for the Membership exams of one of the Royal Colleges. There are a number of Royal Colleges for the different generic specialties (by generic we mean the large specialties, like medicine – not the subspecialties within them like Nephrology). The Royal College of Physicians, for example is responsible for Medicine. We also have the Royal College of Radiology, Royal College of Psychiatry, Royal College of Ophthalmology, Royal College of Obstetrics and Gynecology and so on.  

A doctor becomes a “member” of a Royal College when he passes that college’s membership exams. For example, if a doctor wishes to progress as a surgeon, he will have to pass the Membership exams prepared, administered and assessed by the Royal College of Surgeons. If he is able to pass the exams, he will be an MRCS (Member of the Royal College of Surgeons) and eligible to advance to one of the grades above that of an SHO. These are:

• Staff Grade.
• Specialist Registrar (SpR) Type I.
• Specialist Registrar (SpR) Type II (FTTA).

The staff grade is a post in which the doctor does not have a chance of progressing career-wise to reach a consultant grade. The reason for this is that the staff grade is a non-training post. Training elements incorporated into this post are not formally recognized by the Specialist Training Authority (STA). Since becoming a consultant requires its own training program (that has to be approved by the STA) a staff grade doctor cannot improve on his credentials to become a consultant. The inability of the SAS doctors to progress towards a consultant grade has given this group of doctors a lot to complain about.

If a doctor works in a staff grade for 10 years, he is entitled to an Associate Specialist grade – which is a more senior grade with a higher pay scale. The Staff grade and Associate Specialist doctors are collectively referred to as the SAS Doctors.

Some hospitals have a tradition of actively teaching and training its staff grade doctors on par with the SpR doctors (SpR posts are explained below) – even if this training is not officially recognized by the STA. Therefore, an overseas doctor who is interested in going to the UK primarily to improve his expertise can still do so in a good staff grade job. However it is equally likely for a staff grade doctors to be neglected if the consultants in the hospital don’t make it a priority to actively train them. Staff grade doctors therefore may or may not receive active training depending entirely on the senior doctors who they are working under. The best thing to do for an overseas doctor is to have a CV strong enough to obtain a staff grade post in a hospital that has a long standing tradition of actively training its staff grade doctors.

With regards to the staff grade post, Graham Buckley, the Director of the Scottish Council for Postgraduate Medical and Dental Education, made the following points:

• The posts are not for training. They are non-consultant career posts. [see “Terms not already covered” below for definition of non-consultant career posts.]
   

• Traditionally, the British medical profession has been hostile to the development of non-consultant career grade staff, expressing this through both the BMA and the royal colleges. Grades such as the staff grade…have been perceived as a threat to standards.
   

• It should be clearly understood that the staff grade is not a route to becoming a consultant.
   

• The implementation of shorter and more structured training for specialist registrars, has left a service gap which has been filled by staff grade doctors.
   

• The content of the work of staff grade doctors and their working hours is clearly varied. It is this flexibility in filling awkward gaps in the service that makes these doctors such a key component in the medical workforce and should lead to their achieving higher status.
   

• At present, the staff grade posts seem to be a lottery, with job satisfaction highly dependent on the approach taken by the supervising consultants.

In order for a doctor to attain a Consultant grade (the highest in the NHS) he will have to go through a formally recognized, well-planned, specialty training program called Higher Specialist Training (HST) which lasts from 4 to 6 years, depending on the specialty. A doctor admitted into an HST programme will have the grade of a Type I Specialist Registrar. After completing the HST programme, he will be awarded the Certificate of Completion of Specialist Training (CCST), which entitles him to the Consultant grade.

A doctor in an HST programme as a Type I SpR will be given a National Training Number (NTN), which registers him as a doctor on his way towards a consultancy grade. The NTN is only awarded to those doctors who have permanent resident rights in the UK (i.e., they are allowed to live and work there just like British citizens). Overseas doctors without such resident rights are given a Visiting Training Number (VTN) instead. By awarding VTN/NTNs to aspiring consultants, the NHS manages to keep track of the number of consultants that will be available to the NHS a few years down the road when these doctors complete their HST training. The NHS keeps this careful count of the number of its consultants-to-be in order to avoid creating more consultants in a specialty than are needed. For example, if the NHS predicts that it will require 3000 Cardiologists in the year 2008, it will make sure that the number of VTN/NTNs that it assigns to doctors entering HST in Cardiology does not cause the target of 3000 Cardiologists to be exceeded in the year 2008. The reason they pay such careful attention to the number of consultants in any specialty is because these consultants, being at the top of the NHS hierarchy must have jobs when they finish. After the huge investment made training them, the NHS cannot afford to have unemployed consultants.

Consequently, there is fixed number of VTN/NTNs available to be assigned - the number depending on the needs of NHS at the given time. Competition to get a Type I SpR post is currently very fierce even for UK graduates. This post is, after all, the key to getting to the top of the NHS. For overseas graduates Type I SpR posts in some specialties (such as cardiology, neurology, gastroenterology, respiratory medicine, general surgery and orthopedics) are exceedingly difficult to obtain.

The Type II SpR posts are more commonly referred to as the Fixed Term Training Appointment (FTTA) posts. FTTA posts are also SpR posts. They  identical to Type I SpR posts in terms of content, duties, and training components - however they do not lead to an CCST, which means that they do not lead to a consultant grade. While the Type I SpR posts are contracts that last for four to six years, the FTTA posts seldom for more than 2.

These posts exist for two reasons. Firstly to accommodate overseas doctors who wish to work in an HST programme in order to gain expertise they would return to their own countries with – and secondly to fill deficiencies in the number of junior SpR doctors without creating more consultants than are needed. For the second reason UK doctors, and not just overseas doctors, are eligible to apply for FTTA posts.

In a few years time, the number of FTTA posts will be reduced to almost nothing. Currently, the NHS is facing a consultant-deficiency crisis. It needs more consultants in the system and as a result the work-force space previously occupied by the FTTA posts is being taken over by Type I SpR posts. By doing this, the NHS aims to overcome the consultant-deficiency crisis it is currently facing in a few years time.

Increasing the number of Type I SpR posts at the expense of FTTA posts probably does not bode well for overseas doctors who wish to gain further training in an HST programme. It is widely believed that UK doctors are actively preferred over overseas doctors when it comes to awarding Type I SpR posts. Therefore overseas doctors who previously stood a chance at obtaining at least an FTTA post will have this option cut off for them as well.

To illustrate, the following is an excerpt from the Advice Zone section of a BMJ Careers issue dated June 19th 2004:

Question: What are the chances of a non-European Union resident getting a type 1 training number in orthopedics? Is there any chance that I could be a consultant in orthopedics in the United Kingdom? (I am a Pakistani national.)

Answer: Dr Phil Hammond, the comedian and general practitioner, has recently written a sitcom about an Asian orthopedic surgeon who struggled to get the top London teaching hospital job that he wanted but instead was banished to the Isle of Wight. Sadly, this does reflect the prejudice that remains in the 21st century among the medical community. “Racism blocks the career progression of doctors from ethnic minorities and from overseas,” a BMA report said (BMJ 2003;326:1418). It saddens me to quote such a line, but all the evidence is there that it is no doubt more difficult to get the job you want if you are from  overseas.

Andy Goldberg
Specialist Registrar in Orthopedics
Whittington Hospital NHS Trust

Since the year 2000, which saw a massive increase in the number of overseas doctors coming to the UK (an increase that still continues), the number of overseas doctors attaining Type I SpR posts has been declining steadily.

It is worth mentioning here that a few years back, there were Registrar and Senior Registrar Grades. If you come across these terms you may ignore them. These posts no longer exist - they have been replaced by the SpR posts.

Those who do not wish to train to become consultants or are unable to get a Type I SpR post are compelled to enter the staff grade (which as already been explained)  or Trust Grade Post.

A “trust” refers to a small number of hospitals which are collectively responsible for the population in a certain area (like a county, or a city for example). There are a little over 300 trusts in the UK.

The NHS is very exact about giving trusts the precise extent of financial, structural and workforce resources needed to deliver healthcare to the locality under the trust’s care. Giving too much money or allotting too many doctors to a trust would be wasteful. The size of the workforce in each trust is therefore closely monitored by the NHS.

However, each trust is allowed some flexibility. When a trust feels that it there is a need for a doctor in a certain grade, whatever that grade may be (PRHO, SHO, SpR or Staff grade) the trust will create a post to fill that particular gap in its workforce. The post created to fill this gap is the “trust post”.  The ability of trusts to create such posts as and when needed is essential to quickly fill up gaps in the workforce that may prove to be only temporary. If, as time passes, the trust finds that the gap is permanent, then it will request the central authority in the NHS to increase the number of doctors allotted to the trust in the grade which is deficient.

During the period of time when it is not yet clear to the trust whether this gap will become permanent or not, the trust post remains a non-permanent grade, and its job contract is not a “standard” one. The trust grade doctor does not enjoy any of the privileges that the other “standard” grades provide. Furthermore, since the trust does not know if the gap being filled by the trust post will become permanent, the post offered can be terminated when and if it is thought that the need for the post is not longer there. As a result, the trust grade posts, are not secure and more importantly, they are not be recognized for training.

It is clear therefore that trust posts are created for the benefit of the trusts, not the doctors who work for them in that capacity. This situation has caused much criticism as many believe that trust posts exploit doctors, especially overseas doctors, who are forced to these posts simply because they can’t find a standard post elsewhere.

A BMJ Careers article dated 3rd January, 2004 focused on these so called non-standard grade doctors. A panel of professionals discussed the issue:

Sam Lingam, former chairman of the British International Doctors Association, told the panel that his association advised doctors to take such posts if that was all that was available. "Without trust grade doctors they will have nothing. They will be homeless and jobless." He continued: "We say to them, `take what's there, for now.' There are many doctors who have the PLAB [Professional and Linguistic Assessments Board test] and so are job ready but find it difficult to get jobs. They have great difficulty even getting a clinical attachment. We advise them to take what is available."

 

Steve Field [postgraduate dean of the West Midlands Deanery]…disagreed that doctors should take up such posts out of desperation, calling this "abusive behavior" and the alternative to working at McDonalds or something like it. He said, "We are abusing doctors rather than valuing them."

The lesson to be learnt here regarding trust grade positions is that they can be used by overseas doctors if they are desperate for a job, however it should also be kept in mind that not all trust grade posts are necessarily bad. Some trusts take conscientious responsibility in developing their trust doctor’s expertise during his time there. However, when circumstances permit, one should leave the trust grade when they can get a standard grade post.

Locums are temporary posts in which a doctor fills in for an absent doctor already employed by the NHS. If a doctor in the NHS is sick, (or in case of a woman, requires maternity leave), on study leave, or on vacation, then a locum doctor will be appointed to perform the duties of the doctor on leave. Locums will last for as long as the other doctor is absent from duty and can be in any of the grades. As such, they can last from a few days to a few months, but rarely longer than that. Locums can be in any of the grades, and they have in the past served as a valuable source of money for otherwise unemployed doctors living in the UK, seeking jobs. A locum at an SHO grade for a month can earn the doctor up to 2000 Pounds Sterling, and as such, can greatly relieve his financial difficulties. The job situation and the monetary considerations of the UK option are discussed below.  

Getting a locum can not only provide much needed financial relief, but also valuable UK work experience that will add to your CV. There are locum agencies in the UK through which most junior doctors obtain their locums, but as the locum employer is usually a senior doctor working in the hospital, knowing such a doctor (or someone who can put in a good word for you on your behalf) can be instrumental in securing a locum post.

It is possible to enter the NHS from your own country at different levels of your professional development. Currently the vast majority enter at the SHO grade. In 2006 there will be immense competition for the FY2 grade and in 2007 for the BST grades. Besides the SHO/FY2/BST grades, the other entry points are:

• PRHO - FY1.

• Staff/ Trust Grade.

• Consultant Grade.

P.R.H.O / FY 1
As previously stated, while it is technically possible for an overseas student to obtain his medical degree and come straight to the UK to do his PRHO or “house job” as it is also known, it is very difficult to obtain one. All overseas graduates are strongly advised by the GMC, the BMA, Careers BMJ, and others in the know to do their house jobs in their own countries and not count on getting one in the UK. To be eligible to apply for a PRHO/FY1 post, the doctor is expect to have attained his medical degree, passed the PLAB and have a minimum band score of 7 in the IELTS (this is explained below).

Staff / Trust Grade
To be eligible at all for such posts, the candidate must have secured his Membership with the Royal College (MRC) of his specialty or obtained a degree from his own country of a comparable level (like the FCPS degree of Pakistan). It is not easy to get these posts without any UK work experience whatsoever, and it will help the doctor’s chances of getting such a post if he manages to get a clinical attachment in the UK for a period of time. It is easier to get locum jobs in the Staff/Trust grades than it is to get longer contracts, and an overseas doctor entering at this level would be helping his chances if he concentrated on trying to get locums in this grade first before seeking more long-term contracts.  

As previously mentioned, there are staff grade posts in hospitals reputed for having a good learning and training environment. An overseas doctor might opt to enter the NHS at the staff/trust grade post (after completing his MRC or equivalent in his home country) rather than at the SHO/FY2/BST grade in order to avoid the bad job situation of that grade. Such doctors, with MRCs or equivalent may be motivated to work in the UK for a period of years to gain exposure to medical practice in a first world country along with earning a substantial amount of money during their time there. This is an attractive option for those doctors who can wait 4-5 years (after obtaining their medical degree) before going to the UK. In those 4-5 years, they can obtain their memberships and “grow their CVs” (this is explained below) so their chances of obtaining a good staff grade post is increased. Ultimately, they’ll have the chance to enter the NHS into a well-paid post with a good training element allowing them to improve on their expertise.

Consultant Grade
A senior, well-qualified, experienced overseas doctor can enter the NHS in a locum capacity or a more permanent one. The duration of the contract varies on a case-to-case basis. This is possible at the present time mostly because the NHS is short of consultants and is actively recruiting them from overseas. However, entering at the consultant grade is beyond the scope of this manual (which is aimed at junior doctors).

This sub-section provides information on what a doctor must do in order to enter  the SHO/FY2/BST grades. Practically speaking, the FY2 and BST grades will replace the SHO grade in the next few years. For the sake of convenience the text that follows uses the term SHO, but it should be understood that all the information below applies equally to the FY2 and BST grades.

The chronological sequence of qualifications an overseas doctor must attain to be eligible to apply for an SHO grade are:

• House job.

• IELTS (can be given even in house job).

• PLAB 1.

• PLAB 2.

• Registration.

• Finding a job.

Since getting a PRHO/FY1 post in the UK is very difficult, the overwhelming majority of overseas doctors who go to the UK complete their house job in their home countries.

The IELTS is a test of the candidate’s English skills. It stands for International English Language Testing System. People are required to take this exam to prove they have the minimum acceptable level of proficiency in the English language needed to engage in their academic or work pursuits in the UK, so its not just for doctors. This exam can be taken in many countries, including Pakistan. Currently, it costs around 80 Pounds Sterling and is held twice a month every month throughout the year.

The exam has four sections: Speaking, Listening, Writing and Reading. The result of the test is given as a number on a scale (called band) from 1 to 9. Each band, or scale represents a certain level of competency in English. A score of 1 means that the candidate has only a rudimentary grasp of the language. A score of 9 means the candidate is as proficient as a native English speaker.

Each of the four sections are scored separately on the band of 1 to 9. The individual band scores in the different sections are then added up to give an average. For example, if a candidate gets 8 in Speaking, 8 in Listening, 7 in Writing and 7 in Reading it will give him an overall band score of 7.5.

In order to be eligible to take the PLAB exam, the candidate must have an overall score of at least 7. However, an imposition is made on the individual scores as well. The candidate must have at least 7 in the Speaking section and at least 6 in the other sections. So if a candidate gets 6.5 in speaking, he will not be eligible to take the PLAB exam - even if his overall score is 7 or above.

The IELTS can be taken even while the candidate is still a medical student, although it should be keep in mind that the IELTS result is valid for two years. The candidate must go on to take his PLAB exam within this two year validity period. 

If a candidate gets less than the required band score, he will have to retake the IELTS. He cannot proceed further to take the PLAB exam unless he has received the minimum band score of 7. Furthermore, he is ineligible to retake the IELTS exam in the three months following his current attempt.

Unfortunately, many students and junior doctors in our area have had a real problem with this exam, with many continuing to get lower-than-required band scores even in their second attempt. This exam should be taken very seriously by those who don’t feel confident of their English skills and who don’t read, write or speak the language often in their daily routines.

It should be kept in mind that the IELTS is an exam and like all exams, it has its flaws and weakness which can be exploited to allow a candidate to get through in the end. The candidate may pass the exam because he is feeling particularly sharp or confident on that day, or because the examiner testing his speaking skills was easy-going and brought out the best in him, or because he learnt some ‘tricks’ that got him through. While the exam is eventually passed by virtually everyone, difficulty in passing this hurdle indicates a deficiency in English language proficiency that has the potential to seriously harm the candidate’s future prospects in the UK. Passing an exam and living in a place where good English skills is a professional requirement, are two different things. If a candidate with poor English skills manages to get through the IELTS, his deficiency in the language will eventually come across in job interviews later on, where communication skills and confidence are important standards of assessment.

Therefore, an overseas doctor should be very conscious of the fact that English is the language of his professional instruction and in the UK, the language of social and professional interaction (with everyone from patients to teachers to bus drivers). It is, as such, his life-blood. He should therefore concentrate on improving it for this sake alone, and not for the purpose of passing an exam like the IELTS. Improving on a language takes time, and the earlier a medical student/doctor realizes how important this is to his career and focuses on it accordingly, the greater his chances will be of attaining a level of competency that will make the IELTS a minor exam for him, rather than the sink-or-swim exam it has come to be in many parts of Pakistan.

The Professional Linguistic Assessment Board exam, or PLAB doesn’t actually have a linguistic component, otherwise the IELTS would not be required. Nevertheless, the ‘misnomer’ remains to describe an exam of a difficulty level between that of final year and post-graduate (i.e., MRC) examinations. It has two parts - PLAB Part 1 & PLAB Part 2.

The PLAB is basically a registration examination that allows you to practice medicine in the UK. In that sense it is similar to the USMLE Steps of the US system. However, there are three important differences between the PLAB and USMLE exams:

• The PLAB exam is considered to be far easier, and less costly than the USMLE exams.
   

• There are only 2 parts to the PLAB exam, not 3 like in the USMLE Steps (or 4 if you count USMLE Step 3).
   

• The PLAB is a pass/fail exam. It makes absolutely no difference to your credentials if you pass the PLAB by an extremely wide margin or just manage to get through by a single mark. This is in contrast to the USMLE Step 1 and Step 2 CK exams, in which a candidate’s scores affects the strength of his CV.

PLAB Part I

The first part of the PLAB exam, the Part 1 is administered in a number of countries, including Pakistan where it is held three times a year: in March, July, and November. Currently, the exam cost 145 Pounds Sterling.

In order to be eligible to take the exam, the candidate must be a medical graduate (he cannot give it before graduation) from a WHO-recognized medical college and also have the minimum required IELTS score in hand during the time of application.

The exam consists of a 3 hour paper containing 200 questions. The questions are called “Extended Matching Questions” or EMQs - which simply means they are multiple choice questions with a variable number of possible answers to the questions posed of which the best one is selected.  The exam concentrates on the clinical subjects, not on basic sciences. There are also a few questions regarding medical ethics, evidence based medicine, epidemiology, and public health.

PLAB Part II

This part can only be taken in the UK. Recently, the capacity of the PLAB 2 center in London has been expanded enormously, and now the exam will be held several times a month every month, throughout the year. Currently, the exam costs 430 Pounds Sterling.

The Part 2 is a examination of clinical skills - not a paper-based EMQ exam. The system devised for testing the candidate’s clinical skills is called the Objective Structured Clinical Examination, or OSCE.  

When you start the examination, you will go to your first “station” in which you will be given some instructions. It could be taking history from a patient there, performing an clinical examination, or a number of other things. You will have 5 minutes to accomplish your task and 1 minute of pause to think before each station. There are 14 stations in all, with two “rest” stations – so the exam lasts a total of 96 minutes. The primarily skills tested for are:

• History taking and diagnosis based on history alone.

• Proficiency at physical examination.

• Communication skills with patients.

• Management of emergency cases.

In order to get a job as a doctor, you must be registered as one in the GMC’s register of medical practitioners. The fee for registration is 155 Pounds Sterling.

Currently, there are 4 types of registration:

Provisional: Granted to those in the PRHO posts.

Limited: Granted to doctors who have just obtained their first supervised training posts. It is granted on submission of the job contract the doctor receives from the hospital in which he is hired.

Full: Granted to those who have passed PLAB, and worked for at least 12 months in a supervised training post in the UK. With full registration, the doctor can work in any grade in the NHS – it doesn’t have to be supervised.

Specialist: Granted to qualified overseas specialists.

Starting from the summer of 2005 (some sources say it will be from April 2005), the GMC will introduce reforms on registration procedures for overseas doctors. It will abolish limited registration. From then onwards, all doctors who have passed PLAB will be granted full registration automatically.

This move has been warmly welcomed by overseas doctors in the UK. Currently, overseas doctors need a job contract in order to be granted limited registration. The problem was that it was difficult to get a job without the registration. There was, as a result, a difficult Catch-22 situation in which you needed the job to get the registration, but getting the job was difficult without having registration already. Therefore, the abolition of limited registration represents one less hurdle overseas doctors have to contend with.

With automatic full-registration after passing PLAB, there will probably also be a change in the nature of clinical attachments. Previously, doctors who passed the PLAB and went on to do a clinical attachment could only be passive observers. With full registration, however this will probably change as they’ll be allowed to practically demonstrate their clinical skills. (Clinical attachments are explained in the next section).

After securing the minimum 7 band score the IELTS exam, passing the PLAB exam and getting registered, the next step is to find the first job. This is the hardest part of the entire process. As already mentioned, the job situation in the UK for SHO posts is exceedingly difficult.

Jobs are advertised in the careers/job-opportunities sections of the British Medical Journal (BMJ) in Lancet (another reputable medical journal) and the NHS Careers Website. The jobs are then applied to as per the instructions in the advertisement.

There is a very important point to note here. Jobs are advertised in “seasons” – in that most SHO posts start in February and August and advertisements for these posts start to appear a couple of months before the jobs start. For example, advertisements for jobs starting in August start appearing from April onwards. Therefore it is very important that you plan your move to the UK keeping these seasons in mind. Arriving after a job season is over will make it very difficult to find anything better than a locum or trust grade job.

Another point to note is that with the introduction of the FY2 in August 2006, the job season will only come around once a year. Since FY2 posts last a year, there won’t be any openings for new FY2 posts until that one year is over.

Most medical students and fresh graduates will already know that the job situation in the UK is very dismal. A visit to different online forums for overseas doctors looking for jobs in the UK gives an extremely discouraging picture. In September 2004 the BBC aired a Newsnight feature on the plight of overseas junior doctors. Some of the comments made by the doctors interviewed are quoted here:

“I've not been able to get one single job. You feel so low about yourself. You feel what on earth am I good for.”

 

“Filling time, unemployed orthopedic doctor, Satish Bhat spends most of his days filling in forms. 250 job applications in the past six months. He's left his wife and child in Kerala south India, in search of jobs and training with the NHS.”

 

“The perception in India is that there is a dire shortage of doctors in the UK. I was expecting to get a job at least a few months so far, there's no sign. I keep meeting so many people day in and day out who are in the same boat as I am. They are also here for months on end without any jobs. Without any hopes of a job. Moving from place to place, and totally devastated, totally disillusioned.”

 

“It has been an ordeal here. I'm sure there are several doctors out there who are going through the same nightmare. Who came here with high hopes, and who have ended up being emotional wrecks, who've become so frustrated and disillusioned with the system. I'm sure there are so many of them there.”

Keep in mind that when we talk about the job situation in the UK, it refers mainly to the SHO-grade (in the new system, it will be the FY2 and BST grades). Competition for the higher grades is also very tough, but by the time an overseas doctor reaches a level of qualification that allows him to compete for higher grades, he is already somewhat secure financially. Resultantly, a difficult job situation for a more senior doctor would not hurt as much. The hue and cry about the job situation is coming from junior overseas doctors who come to the UK a year or two after acquiring their medical degree. At present, it is generally accepted that a doctor going to the UK looking for a junior post will have to endure at least 6 months of unemployment before landing his first job. However, there is no telling how much time it will take for the doctor to find a job. The 6 month figure is just an average generally agreed upon by doctors going there these days. It could be more than that - or less.  

Some people contend that the job situation is not really as bad as is publicized and that most doctors who do eventually find a job don’t make it a point to come back to the same forums where they would previously complain about their joblessness. It is argued that persistence pays off eventually, and land the determined doctor a job.

While this may be true, certain points must be kept in mind. Firstly, finding a job might relieve the financial stress that comes with unemployed living, but unless the job is a standard SHO/FY/BST post, there is no guarantee that the job will impart good training. Trust grades for example, are also considered jobs, but there are many trust grade jobs with very poor training elements incorporated into them and in any case, even if there were a training element, it would not be recognized. This is a significant drawback considering the fact that most doctors go to the UK to seek further training. Secondly, the interruption of a young doctor’s training by 6 months to 1 year so early in his career is bound to have some detrimental effect to his competency as a doctor. The blunting of clinical skills over the time he is away from his profession is a problem he will need to work hard to overcome once he finds a job.

The simple fact is that there is a case of supply outstripping demand. There are simply not enough jobs for all the doctors who want one. The best approach an aspiring overseas doctor can take when entering the arena is to be mentally prepared for the hardships that lie ahead. If one comes to the UK thinking that things will go smoothly, then the disappointment he’ll face when things don’t work out that way will be devastating. As long as an overseas doctor anticipates that there will be hardships and troubles to contend with, he’ll stand a much better chance at enduring them when they do come along.

This was not the situation some 5-6 years back. Doctors who went to the UK as early back as the late 90s didn’t have to face such a difficult job situation. Most got their first jobs in a few weeks, if that long. However around the turn of the century, the NHS realized that they were facing a shortage of doctors in the consultant-grade level, and to remedy this shortage they actively advertised job opportunities in foreign countries (like India) asking experienced doctors to seek employment in the UK. This initiative by the NHS created the impression that the UK had become a land of opportunity for each and every type of doctor, regardless of his experience and qualifications. Word spread in the medical communities of India and Pakistan (the two largest contributors of overseas doctors in the NHS) that the UK was the place to go. It was assumed erroneously that the NHS would have ample room for junior doctors as it would for the more senior, consultant-level doctors. Thus around the turn of the century, the exodus began, and it has been increasing exponentially, causing the alarming level of unemployment that we see today.

Currently, an overseas doctor would spend the 3-4 years required to train for his membership examinations in the SHO grade. When he attains his membership, he is faced with the following options:

• Return home (or go to another country) to practice there.

• Try to attain a Type I SpR or FTTA post.

• Work in Trust grade or Staff grade posts.

According to the London Deanery, 10% of overseas doctors leave the UK after they have completed their membership qualification. Of those who choose to remain, 97% of them go into Staff grade or Trust grade posts. Only 3% of them are able to get into Higher Specialist Training in an SpR or FTTA capacity soon after their membership is complete.

Currently, 86% of all Type I SpR posts are reserved for UK-graduate doctors. Overseas doctors may not compete for them. They have to contend amongst themselves for the remaining 14% of SpR posts.

To quote a BMJCareers article dated 17th August, 2002: “As anyone chasing a much sought after national training number (NTN) will know only too well, obtaining a type 1 specialist registrar (SpR) training post is arguably the most difficult and stressful hurdle in clinical training in British hospitals.” This is the situation for UK-graduated doctors back in 2002. The competition amongst overseas doctors is even tougher, and promises to get even more so.

Perhaps this is the reason why most overseas doctors continue to remain in the trust and staff grade posts until they return to their own countries, or retire in the UK. In the NHS, 70% of Staff grade and 62% of Associate Specialists are overseas doctors and most of them will continue to remain in those grades as long as they remain with the NHS. This has been a source of resentment amongst the overseas doctors community who claim that they are being preventing from progressing within the NHS to higher grades because of a bias against them.

For overseas doctors entering the NHS these days, it is clear that the road to a consultant grade is a hard one. Nothing is impossible of course, for the highly accomplished and driven doctor. However for those who are unable to attain a very high level of competitiveness, a realistic goal after membership is a staff grade post with a good teaching and training environment, ensuring that the doctor continues to learn and develop professionally, even if the increase in his expertise over time is not recognized officially. In such a setting, he would evolve to become a competent and professional doctor and that is a goal many would be satisfied with in itself - be it recognized by a degree/diploma/certificate or not.

An overseas doctor coming to the UK must have strong financial support. He will face the possibility of anywhere from two to twelve months of unemployment and during this time he will have to bear his living expenses. He is not allowed to work there (in a non-medical capacity) so his only source of money will be his own savings (if any) or that of his guardians. Therefore the average monthly living expenses for people in such a position in the UK becomes an important issue: How much money will the doctor spend as he looks for a job? There is no one answer to this as the amount of money a person spends for his upkeep is affected by several factors: e.g., where he is living in the UK (cities are more expensive than towns);  whether he is sharing the rent with someone else; his own spending habits; whether he has brought a spouse or family with him, and of course the length of time before he lands the first job.

On average, one can live decently on 400-700 Pounds/month (with rent) in the UK. This cost can be more than halved if one is living rent-free with family or friends. It is up to the individual doctor to look at his financial resources and decide if he can make the investment required to find a job in the UK.

If a doctor was unemployed for 6 months before getting the first job, he would have spent 4,200 Pounds before getting the first job (using 700 Pounds/month as an average). An SHO gets paid about 2,000 Pounds/month. The contract lasts for 6 months which means an earning of 12,000 Pounds during the first job. If he decides to spend his money a little more freely upon getting the job and increases it up to 900 Pounds/month he would still be able to save 1,100 pounds every month during his first job. This means that after completing his first job, he would have 6600 pounds in the bank, easily enough to sustain him for another 6-7 months as he looks for the next job. It is worth noting that the second job is much easier to obtain than first one (because the doctor now has experience in the NHS), and it is unlikely that his savings from the first job would be exhausted before he found the second one.

This will change of course with the introduction of the FY2/BST grades. The FY2 post is of one year’s duration and during this time, the doctor can establish a very sound financial base for himself. However it has to be kept in mind that obtaining the FY2 post may prove to be more difficult than obtaining an SHO post is now. Furthermore, it is not clear yet whether overseas doctors will be offered the full 2-3 year contracts in the BST grades as opposed to 6-month or 1-year stand-alone contracts. Only time will tell how overseas doctors will be treated in the BST grade.

In any case, from a financial point of view, it is the first job which is the most difficult hurdle. At that stage, the doctor has no NHS experience to put on his CV, no letters of recommendation obtained from senior doctors he has worked for in the UK, and no money. All this changes when he gets the first job. If he gets an FY2 post, it will further strengthen his position as he’ll have competency-based assessments to take him forward. If he works really hard during the first job to earn himself good letters of recommendation, spends carefully to save his money, and makes good contacts within the NHS, then the wait for the second job will be shorter and much easier to endure than the first.

The membership exams of the Royal Colleges have multiple parts that are given over a space of a few years. Every Royal College responsible for its specialty publishes a Regulation and Information Manual every year that contains details on the different parts of the Membership exam, their formats, the centers where they can be taken, application forms, fees, rules of exemption from different parts of the exam - and a lot more.

Currently the first part of the MRCP(UK) exam can only be given when 18 months have elapsed from the date of graduation. This prerequisite may or may not change. As we shall see, the NHS is overseeing extensive reforms in the SHO grade and it is quite possible that the membership exam details may be affected by these reforms. One must use only the most current Exam manual from the relevant Royal College to keep abreast of the changing situation.

The MRCP(UK) Part 1 exam consists of two papers in an MCQ format containing 100 questions each. The composition of the different subjects tested in this exam is as follows; the number refers to the number of questions in both papers that will come from that subject.

• Cardiology 15

• Clinical hematology and oncology 15

• Clinical pharmacology, therapeutics and toxicology 20

• Clinical Sciences 25

• Dermatology 8

• Endocrinology 15

• Gastroenterology 15

• Infectious diseases and tropical medicine and sexually transmitted diseases 15

• Nephrology 15

• Neurology 15

• Ophthalmology 4

• Psychiatry 8

• Respiratory medicine 15

• Rheumatology 15

Clinical sciences comprise:

• Cell, molecular and membrane biology 2

• Clinical anatomy 3

• Clinical biochemistry and metabolism 4

• Clinical physiology 4

• Genetics 3

• Immunology 4

• Statistics, epidemiology and evidence-based medicine 5

After passing the Part I exam (the result is mailed 4 weeks after the exam). The candidate is eligible to sit for the MRCP(UK) Part 2 exam. The Part 2 exam can be given 6 months after the Part I exam if the candidate feels he is ready.

The MRCP(UK) Part 2 exam also consists of 2 MCQ papers of 100 questions each. The composition of the exam is as follows:

• Cardiology 20

• Dermatology 8

• Endocrinology and metabolic medicine 20

• Gastroenterology 20

• Hematology/ Immunology 10

• Infectious diseases and GUM 18

• Neurology/ Ophthalmology/ Psychiatry 22

• Oncology and palliative medicine 10

• Renal medicine 20

• Respiratory medicine 20

• Rheumatology 12

• Therapeutics and toxicology 20

If the candidate fails the Part 2 exam, he is free to try again. The only restriction to the number of attempts he can make is that he must pass this exam within 7 years of passing the Part I exam.

The pass result of the Part 2 exam is valid for only two and a half years. The candidate must sit for the 3rd and last part of the membership exam before these two and a half years expire. He is eligible to sit for the third part of the exam 6 months after passing his Part 2. Therefore, the window of time available to him to pass the third part of the exam is 2 years. This 2 year period is called the Period of Eligibility and begins 6 months after the part 2  is passed. To illustrate: if a candidate passed his Part 2 in April 2005, then his period of eligibility for the third part will start from October 2005 and last till October 2007. If he has not taken the last part within the Period of Eligibility, he will be compelled to retake the Part 2 exam.

The last part of the membership exam is called PACES, the Practical Assessment of Clinical Examination Skills. To quote from the 2004 Regulations and Information to Candidates Manual:

“The MRCP(UK) Part 2 Clinical Examination (PACES) is composed of five stations (three ‘clinical’ and two ‘talking’), each assessed by two independent examiners. Candidates will start at any one of the five stations and then move round the carousel of stations at 20-minute intervals until the cycle has been completed. The stations are:

Station 1

• Respiratory System Examination (10 minutes)

• Abdominal System Examination(10 minutes)

Station 2

• History Taking Skills (20 minutes)

Station 3

• Cardiovascular System Examination (10 minutes)

• Central Nervous System Examination (10 minutes)

Station 4

• Communication Skills and Ethics (20 minutes)

Station 5

• Skin / Locomotor / Endocrine / Eye Examination (20 minutes)

The MRCP(UK) Part 2 Clinical Examination (PACES) lasts a total of 120 minutes (including four 5-minute breaks between stations).”

If the candidate passes, he will be awarded the MRCP(UK) diploma.

It should be mentioned here that the MRC diploma, particularly the MRCP(UK) diploma has become internationalized. Training in the UK is not an essential prerequisite to taking any of the 3 parts of the exam. There are MRC exam centers established in 14 countries around the world (Saudi Arabia, Oman, Singapore, Kuwait, and Sri Lanka, to name a few). Pakistan has no such centers, and if Pakistani doctors are training and studying for the MRCP in Pakistan, they must travel to the UK to give them (they cannot go to a non-UK center – those centers are established only for those doctors training there).

There are thousands of MRCs across the world who only go to the UK to take the exam and after passing, return to work in their home countries or seek jobs elsewhere. Obtaining the MRCP(UK) demonstrates a competitive level of competence and can help to further the careers of overseas doctors in their own home countries as well as creating opportunities for them to find jobs in other countries. Many MRCP(UK) doctors, for example, use this qualification to seek jobs in the Gulf states, where this degree is highly valued.

In August 2002, The Chief Medical Officer of the UK published a paper called "Unfinished Business, Proposals for Reform of the Senior House Officer grade”. It had been recognized for years that the General Professional Training administered through the SHO system had many drawbacks. This paper proposed changes to the SHO grade in order to remove those flaws. Subsequently, a body was set up, called Modernizing Medical Careers (MMC) to implement these changes.

The reforms that are being introduced to replace this system are far from universally approved. Many doctors in the UK feel that the reforms suggested by Unfinished Business have as many drawbacks as the system currently in place. Be that as it may, the reforms are due to start on a national level in August of 2005 and only time will tell how effective they will be in improving the current system and (more importantly for us) how overseas doctors will be affected by them.