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.

The previous section “Postgraduate Medical Education in the UK” described the structure of the system in place at the time of writing (January, 2005). This current system will begin to undergo massive restructuring starting from August 2005 to be completely in place by August 2007.

Before getting into the details of the proposed new system, here is a summery of how the present system works - currently, when a doctor ends his PRHO post, he actively competes for SHO posts in a variety of specialties which lasts for 6 months each. He does this for a period of years during which he completes his Membership in one of the Royal Colleges. After doing so, he competes actively for Type I SpR posts in a certain subspecialty, or failing that, enters into a staff or trust grade post. 

In order to understand the proposed new system, you need to understand the old one first so you can correlate the two. To this end, in the text that follows, I have emphasized the correlation between the current system and the proposed new system in order to provide a point of reference from which the new system can be better understood. In the text that follows, my statements of correlation will begin with the words “Compared to the old system…”

For convenience’s sake, the present system (that is, the one still in place as of January, 2005 – the time of this writing) will be referred to from now on as the “old” system and the system set to be introduced in August, 2005 will be referred to as the “new” system.

In the new system, after British medical students graduate, they will enter a 2-year Foundation Programme.

The first year of this programme is called Foundation Year 1 or FY1. Starting August 2005, all British medical graduates will automatically enter an FY1 post. FY1 consists of 3 rotations each lasting 4 months - one in medicine, the second in surgery and the third in another specialty.  

The PRHO post of the old system will no longer exist as the FY1 will move in to take its place. However, compared to the old system, in content and availability of posts, FY1 closely resembles the PRHO post - and as such will represent the same level of difficulty for overseas doctors to attain.

After completing 12 months in FY1 the doctors will move on immediately to Foundation Year 2 or FY2. This will happen in August, 2006 – the date when FY2 will be introduced nationally.

The FY2 is a completely new grade, which did not exist previously. Compared to the old system there is no counterpart for FY2. The FY2 will consist of 3 rotations (in 3 different specialties) lasting 4 months each. Besides specialty-specific exposure and training, FY2 doctor will be also be trained in the following “generic” skills:

• Clinical Skills.

• Effective relationships with patients.

• High standards in clinical governance and patient safety.

• Use of evidence and data.

• Communication, team working, multi-professional practice etc.

• Understanding of the different settings in which medicine is practiced.

• Care of acutely ill patients.

The FY2 was created in order to train doctors in essential generic skills which will be of use to them regardless of the specialty they end up pursuing. Besides this, exposing doctors early on to different specialties will, theoretically, give them a chance to sample different specialties so they stand a chance of making a more informed decision of the specialty they wish to pursue later on. Compared to the old system there was no such post that actively concentrated on these generic skills. In effect, the FY2 post is seen as a major innovation to the UK post-graduate medical system.

During their time spent in FY2, the doctors will be actively assessed by their supervising consultants. In such assessments, the FY2 doctors will have to practically demonstrate that they are competent in the generic skills listed above. If they succeed in doing so, the fact will be formally documented.

In other words, during the course of the programme, the doctor does not need to give any membership exams to prove his competency. His documented assessments will be the qualification needed to move forward after he finishes the programme. This form of assessment is called “competency based” – i.e., a positive assessment will be written for him only when he practically demonstrates his competency to his supervisors - not by passing some exam. Competency-based assessments is a recurring theme in the MMC reforms, and may have significant consequences for overseas doctors, as we shall soon see.

Ultimately, the first batch of “foundationers” will finish the programme in August 2007 and move on to the next stage.

According to a November 2004 Careers BMJ issue,

Three years is hardly any time to implement a new framework for doctors’ training, and yet 2007 is the date set to roll out the full  complement of training reforms for specialist training to be in place. The Modernizing Medical Careers working party responsible for overseeing the changes, openly agrees that there is still a lot to do. According to Derek Gallen, a member of the working party, most of the plans for what happens after exiting foundation programmes are “still up in the air.”

Whatever structure it takes, the next step after the Foundation programme will be to enter an coherent and well-structured specialist training programme. In other words, once you enter the programme that follows the Foundation posts, you should not have to compete for jobs every 6 months, but continue to remain in the same training programme for least a number of years. By contrast, compared to the old system, doctors would have to compete regularly for SHO posts.

Entry into the programmes following the Foundation programme would be made on a competitive basis. The criteria for selecting a candidate will be his competency based assessments, which were made during his time in the Foundation programme. There is no parallel to this compared to the old system. That being the case, an overseas doctor may find it difficult to secure his place in a post-foundation programme without having gone through the foundation programme himself.

As the issue of what will happen after the Foundation programme has to be faced in August 2007, the structure of the post-foundation programme has not yet been formally agreed upon at the time of writing (i.e., it is “still up in the air”). However, currently the consensus is that a post-foundation programme will follow one of the following two formats:

The First Proposal

The first proposal is that FY2 should be followed up a 2-3 year Basic Specialist Training, BST (Keep in mind that if the BST proposal is adopted, it will start from 2007. Therefore, currently the term ‘Basic Specialist Training’ is not in widespread use. I am pointing this out to avoid possible confusion with another BST acronym which stands for Basic Surgical Training. This is a simply 3-day course offered to junior doctors in surgical specialties. It should not be confused for the Basic Specialist Training).

Compared to the old system, the BST is equivalent to the General Professional Training (GPT) a doctor attains during his different SHO posts. Therefore, a doctor in a BST program in the new system would be equivalent to an SHO in the old system.

The BST will be offered in one of the following 8 specialties:

• General Medicine.

• General Surgery.

• Child Health.

• General Practice.

• Obstetrics & Gynecology.

• Mental Health.

• Anesthetics.

• General Pathology.

If a doctor decides to enter a BST programme in General Medicine, he would be rotated through different specialties for those 3 years and will have to complete his MRCP(UK) qualification during that time. Compared to the old system such well-planned rotations through the different specialties of medicine (or any other specialty) was very difficult for overseas doctors who were compelled, by the difficult job situation, to take whatever SHO rotations they could get.

The BST programme will be a continuous, uninterrupted contract lasting 2-3 years (depending on the specialty). After the doctor gets the contract, he will not have to compete for a job until his BST is over. During the BST, he will study for and complete his membership in the Royal College of his specialty. (This is actually very similar to the Residency programmes of in the US system.)

Compared to the old system, the attainment a membership in a Royal College was up to the SHO. He could stay in SHO posts for years and not gain membership. In the new system however, he would have to finish his membership during his BST training period. Once his BST is over, the doctor will compete for a place in a Higher Specialist Training (HST) programme for training in a subspecialty. If for example, after finishing a BST in General Medicine,  a doctor wishes to enter a HST programme in Neurology, he would have to compete for such programmes using his ‘competency-based’ assessment profiles of the preceding years of his career as well as other qualifications he has picked up (by “Growing his CV” - which is explained below). Once he enters the HST programme, he will be given an NTN/VTN and continue for a number of years, without having to compete for jobs, until his HST is over. During the course of this HST programme, he will earn his CCST, Certificate of Completion of Specialist Training and qualify as a consultant.

Compared to the old system, the HST programmes are not a major innovation. Remember, the MMC reforms are aimed at improving the training of junior doctors in the SHO grade. Doctors in HST programmes are not junior, and so this part of the system has not been changed. Even in the old system, the HST programmes were multiple-year contracts in which the doctors were allocated VTN/NTN numbers. Therefore, this part of the old system and new system are the same. The grade of a doctor in an HST programme will be SpR, just as it was in the old system

The Second Proposal

The second proposal is to unify the BST and HST programmes into one seamless programme that lasts 4-8 years (depending on the specialty). This scheme has been nicknamed the “run-through” grade – in that the doctor will come straight out of the Foundation programme and “run-through” a single, unified 4-8 year programme towards a consultant-ship.

The first few years of this “run-through” programme would involve training in the generic specialty, and not the subspecialty. For example, if a doctor entered a “run-through” programme for Gastroenterology, he would not be exclusively trained in just Gastroenterology for the whole 8 years, but be exposed in the first few years to all the other Medical sub-specialties as well.

Compared to the old system, for the first few years of the “run-through” grade, the doctor would be equivalent to an SHO of the old system while the latter years, he would be equivalent to a Type 1 SpR. 

Using Both Proposals

It is quite possible that the different Royal Colleges will adopt different proposals. Currently, it is thought that the Royal College of Physicians prefers the first proposal while the Royal College of Surgeons is leaning towards the second. However, in either case, the doctors will be inducted to the programmes following the FY2 on the basis of their competency-based assessment profiles during their time as “foundationers”. This is a significant point for overseas doctors as we shall see below:

The only difference between the two proposals is that while in the first, the BST and HST are separated, in the second, they are unified. Therefore, for the sake of simplicity, in the text that follows, I will refer to the grade following the Foundation programme as the BST grade.

The short answer is: no one really knows for sure. Some people say it will improve matters, while others say it will make things worse. What is clear however is that most overseas doctors will enter the programme in FY2, not in FY1 (which will be as scarce as the PRHO posts of the old system).

We will only really find out what consequences the Foundation programme will have for overseas doctors after August 2006 when the FY2 is formally introduced. However, in my opinion, things will stand to get a lot harder for overseas doctors in 2006. This is why I believe this to be the case:

One of the fundamental principles behind the “Unfinished Business” reforms is to guarantee continuity of training. In other words, the training of junior doctors should progress seamlessly from one programme to the next, with the next programme building on the progress made in the first. Therefore, the training programme(s) after FY2 will be designed in such a way as to build upon the training imparted during FY2.

Resultantly, the consultants hiring junior doctors into programmes that follow FY2 will assume that the doctor applying has all the generic skills demanded for the successful completion of the FY2. The only way to prove that a doctor has these skills is to have favorable “competency-based” assessments – and these can only be attained by going through the FY2.

Therefore, it follows that when the FY2 is over and doctors start competing for the post-foundation programmes, the consultants hiring people into these programmes will actively prefer doctors who have spent a year in FY2. These FY2 doctors will have competency-based assessment profiles that prove they have the generic skills needed to enter the post-foundation programmes.

Overseas doctors may very well have the same generic skills, but coming from a different medical education system, they may never have been able to formally document them.

Consider again the generic competencies that an FY2 doctor is supposed to have attained:

• Clinical Skills.

• Effective relationships with patients.

• High standards in clinical governance and patient safety.

• Use of evidence and data.

• Communication, team working, multi-professional practice etc.

• Understanding of the different settings in which medicine is practiced.

• Care of acutely ill patients.

An overseas doctor may know precisely how to establish an effective relationship with patients, or how to work in a team, or understand the different settings in which medicine is practice – but how will he prove it? While the FY2 doctor will have been actively assessed by his seniors, the overseas doctor will not have had the advantage of such documented assessments.

This leads us to the possible creation of an immense problem: If FY2 doctors are going to be actively preferred for post-foundation programmes, then every overseas doctor coming to the UK in the next few years will concentrate on applying for this one grade, the FY2  because obtaining this post will maximize his chances of getting into a post-foundation programme. Currently, overseas doctors can apply for SHO posts. SHO posts don’t have a clearly defined, hierarchical place between the PRHO and the Staff-grade/Consultant grade post. The SHO posts are currently a set of jobs that fill the blank needed to get the Membership training experience. With the advent of the FY programme, this vague gap will be removed. From 2007 onwards, junior doctors will either be in a Foundation program or in a post-foundation programme. Since the surest way of obtaining a post-foundation programme is to come from a Foundation programme, and since the only entry level for overseas doctors will be an FY2, overseas doctors will descend, in their thousands, on the limited number of FY2 posts in the year 2006.

Keep in mind that this is speculation (and my own personal theory at that) and may prove not to be the case. For example, one could argue that the NHS is actually introducing a new grade: the FY2. And because of the introduction of a new grade the job situation may not change appreciably.

The fact that I’m speculating at all, and not citing references and sources that give precise predictions of what will happen should in itself communicate the fact that great uncertainty prevails with regards to this issue amongst the overseas doctors community in the UK.

Another likely effect of introducing the Foundation system is a reduction in the “job season” from twice a year to once a year. Currently, in the SHO system, the jobs are available in February and August. However, with the Foundation system, since the FY2 (by definition) is a one year contract, they will only be advertised once a year (before August)

It is also unclear how easy or otherwise it will be for overseas doctors to enter the BST programmes even if they have done the FY2. Will the traditional bias against overseas doctors hoping for a training post that leads to an CCST prevail and carry over when they apply for BST programmes? Will overseas doctors be given 1-year (or less) stand-alone contracts in the BST programmes? And how difficult will it be for overseas doctors without an FY2 qualification to enter directly into BST?

These are questions to which those in the Modernizing Medical Careers themselves don’t have confirmed, guaranteed answers. We will all find out when the times comes, that is 2007 when the BST programmes are scheduled to start.

This sub-section should convey to you the uncertain job situation for overseas doctors of the next couple of years and encourage you to keep abreast of the situation in order to maximize your readiness when the time for the move to the UK arrives. No doubt, the situation will become clearer somewhere in 2006 as the Foundation ‘graduates’ enter the next stage.

Whenever there is intense competition for jobs in any field, not just medicine, the fundamental principle for success is to be amongst the best.

If there are as many as 1000 job applicants for a single post (and this indeed has been reported to be the case in many instances), the consultant who is hiring you must have a reason to choose you over the other 999. The first point to remember is that SHOs actively contribute to the NHS. They are not just taking from the system by obtaining a valuable training experience, but they are also giving back to it by rendering their own expertise. Therefore, when a consultant sits down and goes through a stack of applications and CVs, he is looking for someone who can do a very good job as an SHO.

The key to improving your chances then is to convince this consultant that you will be able to do the job better than everyone else who has applied.

In order to do this, you must first know which credentials are highly valued and sought after in applicants to the SHO post and then strive to obtain them.

Most doctors who go to the UK have an MBBS degree and a PLAB pass - and that is all. These two are the only pieces of evidence documenting their credentials. It is not surprising then that most doctors who go with little else on their CV besides these two accomplishments find it difficult to get jobs. A medical degree and a PLAB-pass are the minimum acceptable criterion needed just to apply for SHO posts in the first place. Having only this, and nothing more will not make you competitive. The consultant hiring you must have a reason to choose you amongst the other hundreds of applicants – all of whom also have medical degrees and PLAB passes. 

“Growing you CV” is an important concept that was covered in some detail in a BMJ Careers issue in June 2004. The principle behind it is to work diligently at acquiring medically-related, documentable credentials that can be included in your CV as evidence of your ever-increasing skills (and hence, worth) as a committed professional.

The process of growing your CV starts in medical college. There are numerous things a student can do that can be placed in his CV years later when applying for jobs.

The Community Medicine research project is a wonderful opportunity to familiarize yourself with Research Methodology. If you work very hard at it and do the job properly, you stand a good chance at publishing your work in a medical journal. It doesn’t have to be an internationally indexed journal. A local medical journal will do just fine. After all, no one expects students to produce original research material of an standard that attracts the attention of professional researchers and clinicians. The acceptance and publication of your work while still a student will say a lot about your dedication and application of basic research methodology so early in your career and this will add immensely to your CV.

Probably the best investment a student can make is to become an actively participating member of the International Federation of Medical Students Association (IFMSA). This can open up a world of opportunities for you. As a member, you will be able to participate in countless workshops, conferences and seminars around the world – which, of course includes Pakistan. There will be other opportunities as well. For example, I myself had the chance to be a reviewer for the World Medical Association’s Undergraduate Manual of Medical Ethics. The manual is available now in medical colleges throughout the world, and my name is in it. When I put this down in my CV, the consultant reading it will know that have at least a rudimentary grasp of Medical Ethics as well as the relevant language skills needed to review such a piece of literature. I was only able to know about the opportunity because I am an IFMSA member. This career manual you are reading right now is itself a credential that will go on my CV and add to it, and again, it is being done in my capacity as an IFMSA member.

During your time as a student, you should avail each and every opportunity to grow your CV. Take part in workshops, attend seminars, organize medical events – and try to learn as much as possible from these experiences. Don’t do it just so you have something to write in your CV later on. The CV after all, is a reflection of your professional self and not just a laundry list of accomplishments. The attitude of doing something just for the sake of the CV is unprofessional in itself and such an attitude will not take you far, even if it does manage to get you your first job.

The time spent as a house officer is often wasted. Little if any studying is done, and after the novelty of working in a hospital as a  doctor wears off, most doctors just do the minimum amount of work expected of them. After settling into the house job, the doctor can use his valuable 12 months doing a number of things like audits, research, paper presentations, and courses.

Audits.

Simply put, an audit is a study undertaken to determine whether any component of  a health-care delivery system is functioning optimally or not. An audit is not the same thing as research. In an audit, no new medical knowledge is gained – the focus is on the medical system itself and not the science behind it.

To give an example - an audit was carried out in the Camden and Islington Community Health Services NHS Trust, to assess how many patients met their first appointment scheduled with their psychiatrists. The audit found that patients who had to wait more than a month for their appointment date usually did not come at all. Based on these findings, the audit recommended that ‘party clinics’ be held in which around 10 patients would have a joint session, thereby introducing the psychiatrist to the patients before ‘real’ one-on-one sessions could be initiated. A second audit was done to follow up the effectiveness of the recommendation, and it was found to work.

Audits are given great importance in the UK and are seen as the main tool to maintaining and continuously monitoring the standards of health-care delivery. A doctor having conducted several audits would be helping his CV immensely. It may not be easy to conduct a audit in a hospital that does not have the proper infrastructure or well-established inter-departmental communication, but an effort to overcome such difficulties is worth attempting. Most UK graduates have conducted several by the time they are SHOs and every attempt must be made by an overseas doctor to have several audits in his CV when he applies for jobs in the UK.

For more information on audits, you can download the “Principles of Best Practice in Clinical Audit” published by the National Institute of Clinical Excellence in the UK - a very comprehensive document (some 200 pages) and available free online. It is the authoritative document on audits.

Research.

A house officer will have much greater access to patients and as a result will be in a much better position to do small clinically oriented research projects. If that is not possible, any other small research will do – it could be a retrospective study. However some research should be done during this time. As previously mentioned, published research adds dramatically to your CV, and by the time you enter the house job, you should be in a position to elevate the standard of your research skills.

In a Careers BMJ article dated 16th November, 2002, overseas doctors aspiring to come to the UK were given the following advice:

 “Once you have decided to come to the United Kingdom, don't waste valuable time in gathering postgraduate or service experience in your own country— the sooner you make the move, the better. The reasons for this are twofold. Professionally, you are not too far down a particular career path and so are in a better position to choose a specialty that offers the best chance of progress at that time. Socially, you are more likely to be free of the responsibilities that come with age and so are more ready to accept, for example, an academic position that may be good for your career but often brings a poorer salary.”

This may have been sound advice back in 2002, when the job situation had not yet reached the levels of difficulty seen now.

Dr. Elitham Turya, a Consultant in Child Health, contributor to Careers BMJ, and author of the book “Your Career After PLAB” wrote to me with the following advice:

“Work in Pakistan for about 2 years. Use the time to do one or two short research items and 2 or 3 audits to describe in your CV.  Most doctors will have MB BS and will have passed PLAB. So why should one candidate and not another be picked? The audits and research (short items- a few months’ works, could be retrospective study) will improve your CV.”

It seems that currently, it would be better to stay back and “grow the CV” in order to improve your chances of getting a good post in the UK.

Therefore if possible, a doctor should enter the post-graduate medical system in Pakistan after the house job and work there for a year using that time to further grow his CV. If it is not possible to start working immediately as a post-graduate doctor, then the “extra” one year could be spent in a non-paid attachment with a hospital. During the additional one year, more research studies can be done (this time, more substantial and demanding ones), more audits, more presentations, with more conferences and workshops attended. All this will go straight into the CV that will as a result become considerably stronger compared to that of the doctor who went straight to the UK after his house job.

Workshops.

The College of Physicians and Surgeons of Pakistan (CPSP) holds workshops on a regular basis (see the Pakistani section of this manual for more information on these workshops). The workshops last 3-5 days and provide good credentials, all of which will look good when added to the CV.

The CPSP offers workshops on “Computer and Internet Skills”, “Research Methodology, Biostatistics, Dissertation Writing”, “Communication Skills” and ”Basic Surgical Skills”. The CPSP provides doctors attending these workshops certificates to attest to their participation.

Membership Exams.

If the doctor spends an additional year after the house job, he can avail that time by studying for Part I of the membership examinations. If he works hard, then by the time he is ready to go to the UK, he should be able to pass the first part of the Royal College membership exam of his specialty. This is a great addition to the CV, and quite achievable if he is able to stay back an extra year after his house job.

Therefore, by firmly adopting the concept of “growing your CV”, a doctor who goes to the UK two years after he graduates should have (if he works very hard) the following on his CV when he goes to the UK:

• 2-3 Research articles.

• 2-3 Audits.

• 2-3 Workshops attended.

• 2-3 Paper Presentations.

• Part 1 of the Membership exam.

This is compared to the those doctors who only have the minimum criteria when they go to the UK: a medical degree and a PLAB pass.

The first thing you’ll need to do upon entering the UK is to complete the PLAB by sitting for the PLAB 2 exam, so you must organized your schedule accordingly. If you have studied and are confident enough of your knowledge, then you should sit for the first part of your membership exam.

Upon finishing these exams, you should start your clinical attachment.

Clinical Attachments

A clinical attachment is a period of time where a doctor is allowed into the hospital as an observer. He can attend the rounds, clinical meetings, ask questions, see how things work, etc… A clinical attachment can last from 6 weeks to 4 months. It is unpaid (in fact, a few trusts in London now require payment) and accommodation is usually not provided in the hospital – even if it is, you’ll most probably have to pay for it.

Currently, the doctor isn’t allowed to do any practical clinical work - although with the change in the GMC registration policies (in which doctors are granted full registration after passing the PLAB) this may change.

A clinical attachment provides a formal, supervised, hands-on introduction to the NHS system and is a chance to make a good impression on a consultant who can later act as a reference. Both are a major boost to a doctor’s CV.

Clinical attachments went from being considered a favourable addition to a doctor’s CV a few years back to being practically indispensable. For overseas doctors, getting a job as an SHO is next to impossible now without a clinical attachment. As a result, the demand for clinical attachments has now approached the demand for jobs. Most overseas doctors new to the UK, apply for clinical attachments before going on to apply for jobs.

Resultantly, it has become very difficult to secure a clinical attachment and it is strongly advised that an overseas doctor secure a clinical attachment for himself before coming to the UK.

It is worth emphasizing this point again: Getting a job without exposure to the NHS is extremely difficult with the current job situation. Recently, it has been observed that doctors coming to the UK spend months trying to secure an attachment. Doing a clinical attachment provides no sure guarantee of job immediately afterwards, and the doctor may well be jobless even after having done 2 or 3 clinical attachments. It is only logical then that the time spent trying to secure a clinical attachment should be spent in the home country, where there are no problems with living expenses or accommodation.

There is no standard, formalized way of acquiring an attachment in the UK. Currently all attachments are organized by personal, direct interaction with a consultant who will ultimately become your supervisor and be the one responsible for you. It may not be the consultant who you first approach, but someone else who can in turn approach the consultant on your behalf. It is ultimately all about getting the consultant’s attention and convincing him to allow you to be ‘attached’ to him for a period of time.

There have been a few trusts that recently decided to centralized and formalize the process of clinical attachments. The Calterdale and Huddersfield Trusts for example released a Clinical Attachment Policy statement in November 2004 in which they decided that all further applications for clinical attachments be directed to their Post Graduate Medical Education department, who would in turn contact the relevant consultants. The introduction of a standardized system of processing clinical attachment applications may be hurried through due to the immense demand for them. The Calterdale and Huddersfield Trusts have made a start, but it is not sure how many others will follow suit, and its is also not clear if doing so will remove the need (or effectiveness) of appealing personally to a consultant.

Since clinical attachments have practically become a pre-requisite to a job, it is important to understand how to obtain one, how to conduct yourself when doing one, when to apply for one, how much it will cost, etc… Such detail is beyond the scope of this manual, but it should be appreciated by the reader that every effort must be made to secure a clinical attachment and due attention must be given to it when preparing to leave for the UK.

Courses.

There are a number of courses offered in the UK you would do well to include in your CV.

For those planning to go into surgery, the ATLS, Advanced Trauma Life Support, the Basic Surgical Skills Course (BSS), and Care of the critically ill surgical patient (Ccrisp) Course are all good additions to the CV. These courses cost around 400-500 Pounds and last for 2-3 days. Due to the expense involved, it is unusual to find an overseas doctor applying for his first job with more than one course in his CV. These courses are, however, a good investment and it is worth taking another one after you have obtained the first job and have some more money in your hands.

For the medical specialty, the ALS, Advanced Life Support Course is being taken by overseas doctors in increasing numbers. It also costs around the same amount, and lasts for 2-3 days. There are not many other courses in the medical specialty suitable for doctors wishing to enter the NHS at the SHO level, so taking this one course would be a good investment.

With little time to spare in his busy schedule, and with hundreds of CVs to look at, the consultant will literally not spent more than 60 seconds looking at your CV. However your CV is you. It is a record of your life – it describes how well-qualified you are and why you are the best applicant for the job. When writing your CV, make sure that whatever is in those 5-6 pages is presented so well, and so clearly that it jumps out from the page to capture the reader’s attention, causing him to pause and consider you as a serious contender.

Perfectly good credentials that may earn an individual the job may be wasted if they are tucked away in some corner of the CV where it might escape the reader’s attention. The CV should not so much be written as designed. It has become something of an art and is a skill that you should learn well. Sometimes, you may have to apply for a job in which some of your credentials will be more important that others, in which case you would help your chances by sitting down and redesigning the CV so that it is optimized for that particular job.

There is no one correct way to write a CV, although there are many incorrect ways. Although certain basic rules do apply, do not think there is one format out there that maximizes success. Keep asking yourself if there is anything you could do to present your credentials in a better way.

It must be emphasized however that if a candidate comes to the UK without any credentials, experiences, or qualifications to write in his CV, then any amount of tinkering and designing will not change that fact.

When a consultant decides that he likes what he sees in your CV, he will short-list you for the job and call you for an interview. He will also call a number of other doctors for the same post. Only one of them will get the job, and it is the interview which decides who that one person will be.

In the interview, the consultant(s) may ask you some medically-related questions, but if you have managed to come this far, what he is really assessing is how you present yourself. If you have a great CV with a long list of qualifications, but you comes across in the interview as unpleasant, rude, or too timid and lacking in confidence, the consultant not be inclined to choose you. 

You must present yourself well and come across as a confident, competent, and likeable person. These are after all, qualities any patient would want to see in his doctor and therefore are the traits consultants are looking for as well.

The interview is also a time where your communication skills will be given careful attention. If the consultant feels you have poor communication skills, it will be a big blow to your chances of landing the job. This again emphasizes the need to be very well versed in the English language. As previously mentioned, passing the IELTS is by no means the end of the demand you must make on your English language skills. You must, in this highly competitive time, by very proficient in the language.

• Basic Specialist Training OR General Professional Training

This refers to the training received at the SHO grade.

• Career Grades

The non-training grades - namely the Consultants, Staff grades, Associate Specialist Grades, and the trust grade posts.

• Non-Consultant Career Grades

Synonymous with the Staff and Associate Specialist grades. Doctors in the SAS/NCC grades cannot progress further up the NHS hierarchy because they are non-training posts. The emphasis on this grade being a “non-consultant” one is made because while a consultant grade is a career grade, it is at the top of the NHS hierarchy and as such, highly regarded. All other career grades (i.e., the “non-consultant ones) are seen to be (often frustratingly) dead ends to further NHS progression.

• MRCP; MRCS

An MRCP(UK) doctor is a Member of the Royal College of Physicians of the United Kingdom. The MRCP(UK) refers not only to the member, but is also used to refer to the exams needed to pass to become a member, e.g., MRCP Part I exam and so on. The MRCP exam deals with the specialty of medicine. A doctor must be an MRCP(UK), in other words, he must have gotten ‘his membership’ before being able to proceed to Higher Specialist Training in a medical subspecialty.

There are other “memberships” like the MRCS, which stands for the Member of the Royal College or Surgeons.  Each specialty in the UK has its own membership exam and passing them will give you the “membership” into that Royal College.

• FRCP

When a member of a Royal College of Physicians stands out in his career as having high academic output, as being ethical (and a number of other criteria), he can be considered for elevation to a Fellow. No exam is taken to become a Fellow – a doctor is considered for a fellowship by the Royal College of Physicians only after receiving written recommendations by two other doctors (who must be Fellows themselves). The Royal College will consider the applications of the two Fellows who recommended the doctor and if the Royal College approves their recommendation, they will grant the MRCP doctor a fellowship after which he will be entitled to refer to himself as an FRCP. It is simply an honorary title, and does not change anything besides cementing the doctor’s reputation. This “Fellowship” should not be confused with the Fellowship of the US system, which is earned after passing through a certain, specific programme.

• FRCS

The process of becoming a Fellow of the Royal College of Surgeons is exam based, unlike the FRCP. It is taken near the end of a surgeon’s Higher Specialist Training, with the exam being different for the different sub-specialties – for example an FRCS(UR) is a surgeon in Urology and an FRCS(NS) is a neurosurgeon, etc.

• Honorary or supernumerary post

An honorary post is an unsalaried post. The doctor may receive funding from a grant, fellowship or bursary. A supernumerary post is a post that has been created by placements additional to the agreed number of trainees in approved training posts. A post may be both supernumerary and honorary.

• Rotation

This refers to the move from one post or specialty to another. In a period of employment a doctor may have one or more rotation.

• Substantive Post

A substantive post is an established permanent post.

• Locum Appointments for Training

A Locum Appointment for Training (LAT) is created when there is a vacancy in a recognized training post. The entry criteria for a LAT are the same as for an SpR appointment; the trainee would be appointed at interview in open competition. Each LAT will be three months or more, up to one year, of training in an appropriately approved post. LATs may be accredited towards a CCST programme by the Regional Adviser when the trainee has obtained an VTN/NTN.

• Locum Appointments for Service

A Locum Appointment for Service (LAS) does not receive any credit for training and should normally be limited to three months.

• Programme

A formal alignment or rotation of posts together comprising a programme of training in a given specialty(ies) which counts towards the award of a CCST.

• Specialist Register

A formal listing of all doctors who are in Type I SpR training. From 1 January 1997 inclusion in the Specialist Register became a legal requirement for taking up a substantive Consultant post in the NHS. (Do not confuse with Specialist Registrar)