The Overseas Doctors Training Scheme: failing expectations

Medical heritage

Britain has a long tradition of providing postgraduate education for overseas doctors, and rightly or wrongly many doctors think that a British medical training is superior to most. In its brochure on postgraduate training for overseas doctors, the Royal College of Physicians states that “our role in training graduates from countries with an historical link with Britain is regarded as a special and rewarding responsibility.”

The pragmatic truth, however, is that Britain has needed overseas doctors to fill junior posts, especially unpopular ones,4 and many who have come have been sadly disappointed with the training they have received. In 1982 Sir David Innes Williams, then director of the British Postgraduate Medical Federation, spelt out the problem: “For many years some overseas doctors have been forced to find employment in the narrower specialties such as ENT surgery, geriatrics, or mental handicap, which are almost always inappropriate to their training requirements.”5 Little has changed since then. Sir David went on to propose that a special scheme should be set up for these doctors, pointing out to xenophobic colleagues, fearful of encouraging yet more overseas doctors to come to Britain, that “Over 85 per cent of overseas trainees who come over to Britain leave, and although a minority who stay do not achieve their educational goals and end up as “stuck doctors” in unsatisfactory posts, the expansion of many branches of the health service would not have been possible without the [majority's] participation.”

A good idea

In 1984 the Council for Postgraduate Medical Training in England and Wales approved Sir David's proposal and the Overseas Doctors Training Scheme was set up.6 This, in outline, was, and remains, as follows.

An agreed proportion of posts approved by the royal colleges, at senior house officer and registrar levels in general medicine, general surgery, and some of their related specialties were to be made available for trainees on the scheme, with a few at senior registrar level for suitable candidates. Suitably qualified and experienced overseas doctors would be appointed to these posts for a maximum of four years and receive structured training relevant to their needs. The placing of trainees would be left to the discretion of the employing authorities. The number of doctors selected for the scheme would “not exceed the training opportunities available.”

Criteria for acceptance on to the scheme have changed little since its inception. The accompanying article (p 1624) gives information on qualifications and sponsorship requirements.7

Falling victim to success

Each of the royal colleges started its Overseas Doctors Training Scheme independently. The administrative costs were borne largely by the Department of Health. In the past few years, however, the colleges have had to contribute more, for the department has shown increasing reluctance to support a scheme that it envisaged should run on a self supporting basis.

The first college to establish the scheme was the Royal College of Obstetricians and Gynaecologists in 1986. In common with the other colleges, it promoted its scheme widely and interest grew rapidly (box 1). The Royal College of Surgeons of England's scheme started soon after that and quickly attracted even more applicants. “By 1992,” said Mr R M Kirk, a director of the scheme, “we had had more than 10 000 enquiries and 2000 formal applications.” Overwhelmed, the college had to close its lists for two years and started accepting new applications only last spring.

A total of 346 doctors have passed MRCOG. Of these, 163 have gone home and 181 are still in Britain (135 have full registration with the GMC, 46 are still on limited registration)

Since the scheme began 52 doctors have had their sponsorship withdrawn, 16 after adverse reports. A further three have had their sponsorship suspended

Currently, the Royal College of Surgeons has 239 overseas trainees in post, most in general surgical jobs (box 2). The waiting list stands at 60, and most of these will be found a suitable post within two years. The list was whittled down by writing to all those who had been on it for more than two years and telling them that there was no likelihood of them being found a suitable post. Those who had not, as requested, provided the college with an update of their progress and confirmation that they were still seeking training were also excluded. In an attempt to prevent the unfortunate experience of the few who had come over to England in the hope that the college would allow them to leapfrog up the list, the precautionary measure was taken, in 1991, of adding a clause to the briefing document making it clear that applicants arriving in the United Kingdom prematurely would automatically be struck off the waiting list.

At the Royal College of Physicians of London the story was much the same. Promotion of the scheme resulted in a huge demand and the college was forced to “suspend consideration of further applicants” in May 1990. Despite this, it has received 1290 written inquiries in the past three years, of which a third are from candidates whose curriculum vitae suggest that they are of high quality and eligible to join the scheme. Statistics collected last May showed that only 219 on the list had been found jobs; 536 were awaiting placement, and 925 applications were being processed (box 3). Figures for the Royal College of Psychiatrists scheme are shown in Box 4.

Administrative challenge

Dealing with this number of inquiries, vetting individual applicants, and keeping track of those who have successfully been placed is no easy task. Yet most of the schemes are run by a skeleton staff of one or two administrators under the overall control of a fellow of the College. Most of the directors of the schemes are retired and work part time, on an unpaid, honorary basis. For most it is their personal experience of working in developing countries, coupled with a real concern to help overseas graduates, that has prompted them to take on the job.

Getting on to the sponsorship list entails about a year's worth of paper exercises. Then the General Medical Council (GMC) decides whether a candidate is eligible to join the scheme, and ultimately grants (or refuses to grant) limited registration with exemption from the PLAB (Professional and Linguistic Assessments Board) examination. On paying a fee of pounds sterling 400 candidates are granted limited registration for one year only. The GMC will grant a second or subsequent year's limited registration only if feedback on the doctor concerned is satisfactory.

Once a doctor is on the sponsorship list, the waiting game begins. The British sponsor puts the applicant's name forward for a job. Those on the college's list get their name put forward once the regional advisers have notified the college that a job is available. The problem with this system - and it is a big problem - is that consultants do not like appointing junior staff “sight unseen.” An acceptable candidate in the waiting room is clearly more likely to stand a better chance than a marginally more promising one represented solely by a bundle of notes. Furthermore, with few jobs specifically kept for them, trainees must compete with all comers, which includes the many overseas doctors who come to Britain independently and gain limited registration by virtue of obtaining a higher medical qualification or passing the PLAB examination.

Lack of uniformity

Once they are in a job, the trainees' progress is, or should be, monitored carefully. Trainees on the Royal College of Surgeons' scheme fill in a log book documenting their experience and write a small dissertation every six months. “We also get reports on them every six months,” said Mr Kirk, “and we investigate any questions over the candidate's performance.”

Such close monitoring of trainees has by no means been universal, especially of those who have been sponsored by individual consultants, a means of sponsorship that has only just (as of 1 April) been abandoned. Furthermore, the schemes are not run in a uniform way. Each of the royal colleges operates autonomously, and their approaches differ. The Royal College of Physicians of Edinburgh's scheme, for example, mostly takes on inexperienced doctors seeking to obtain the MRCP. Trainees are found unpaid clinical assistant attachments. If they pass the examination they can get full registration and apply for a proper job. This has the disadvantage of excluding those who cannot afford to come to Britain and support themselves. It also means that even if they can afford to support themselves in the short term, failure to get membership at the first or second attempt and subsequent failure to get a substantive paid job can lead to serious financial difficulties.

The problems

Right from the start concerns were voiced, and have continued to be voiced, that the pitfalls inherent in the Overseas Doctors Training Scheme were not being addressed adequately.^8,9,10 A major problem has been the failure to provide a sufficient number of suitable posts for the candidates. Many who thought that acceptance on to the scheme would guarantee them a relevant, high quality, well structured, four year period of training have been disillusioned. The British sponsor is responsible only for finding the trainee's first job, and this may be for only six months. Thus, although the scheme was started with a view to there being special jobs allocated to overseas doctors, in practice there are relatively few visiting senior house officer and registrar jobs. The Overseas Doctors Association claims that trust hospitals in particular are reluctant to fund posts for overseas doctors.

For able doctors this may not provide too much of a problem, but the quality of trainees varies appreciably, especially among those who have been sponsored by individual consultants. Why some trainees have not flourished and some consultants view the scheme with scepticism is thus not hard to understand: A “worst case scenario” might run like this: consultant physician A from St Elsewhere's visits India. An old acquaintance mentions that he has an excellent protege, doctor Y, who hopes to come to Britain for training. Consultant A sponsors doctor Y, who in practice is not as good as his Indian sponsor suggested. After a poor performance in his first job, doctor Y is repeatedly rejected at subsequent interviews. Disillusioned, doctor Y takes an unpaid attachment, does the odd locum, and travels the length and breadth of Britain in search of a job. Eventually doctor Y gets one in an unpopular region, in a specialty he is not interested in. After that no one employs him. Demoralised and in debt, doctor Y turns to his original sponsor for support. None is forthcoming, and the college cannot help him. His prospects of getting a job in his home country are poor because he has not succeeded in getting the specialist training he sought.

“I am sympathetic to such individuals,” said Sir Eric Stroud, director of the Overseas Doctors Training Scheme at the Royal College of Physicians, “but what can I do? These chaps come into my office and break down in tears in front of me, but it is extremely difficult to place someone with a poor track record. (It is difficult enough to place good candidates.) If I find him a post, it endangers the credibility of the scheme - which depends on us supplying good quality doctors - and denies a better candidate the chance to come over.”

Discrimination

For other overseas doctors, the failure to flourish has not been directly related to their academic ability. Discrimination against them in the job market seems to be a real problem.^11,12 Coping with racism, prejudice and cultural differences can also be difficult.13 The Tavistock study of junior doctors showed that overseas doctors “face difficulty at every turn ... their remoteness from home and family support, their conflicts with consultants and other members of staff and their failure to get jobs ... for which they see themselves qualified. Some write many letters of application (one spoke of writing hundreds) but are repeatedly rejected. Others settle for expediency, applying for and getting only those jobs ... which they know few other doctors will want ... In one sense they form an underclass within the NHS. They are assumed to have been relatively poorly trained in their home countries, and accepted on sufferance.”14

Talking to overseas doctors, I found tremendous variation in experience. Clearly, many able and motivated doctors are making an excellent job of tailoring suitable training schemes to meet their needs.15 But all can tell of colleagues who have run into serious professional and personal difficulties, although few are prepared publicly to voice any criticisms of their host country. In addition, the Overseas Doctors Association perceives that Britain is becoming less and less interested in - and less accommodating towards - overseas doctors. “Some hospitals used to provide free board and lodging to overseas doctors on unpaid clinical attachments, but this practice has been abandoned as hospital budgets have been honed,” said Dr Akram Sayeed, chairman of the association. “And since last October overseas doctors have had to pay pounds sterling 120 a month for the privilege of sitting as an observer in casualty or outpatients.”

How many come, where from, and why

An idea of the number of overseas doctors who come or seek to come to Britain can be gleaned from the General Medical Council's figures. “We received about 10 000 inquiries last year and about 2000 people took the PLAB test in 1992,” said Mrs Heather Cope, deputy registrar of the GMC. Initial grants of limited registration have been rising steadily. Of these, only about 40% are to doctors who are being sponsored under the Overseas Doctors Training Scheme. Recent figures from the Department of Health show that increasingly large numbers of overseas graduates are being employed at senior house officer and registrar level (table).

Most of them come from India, and many come from Nigeria, Egypt, and Pakistan (figure). The reasons they come vary. Some seek specific higher training that is not available at home, or they seek to supplement their training and broaden their experience. Others come because they believe the training may be better or to get British postgraduate qualifications which have some cachet in the international marketplace. Yet others come because they have been unable to get on to postgraduate training schemes in their own countries - in countries such as India, competition for limited places is fierce and the patronage system arcane.

Trainees in post in Royal College of Surgeons of England Overseas Doctors Training Scheme, 1994

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That Indian doctors in particular should seek to come to Britain in such large numbers is, some believe, an indictment of the Indian health care system. “Despite soaring health expenditure, and large numbers of doctors, we are failing to meet the primary health care needs of the majority of our people,” said Dr N H Antia of the Foundation for Research in Community Health, Bombay. “The problem is that 80% of our doctors work in urban areas where the pressure to provide high technology, Western style medical care to the articulate and well informed middle classes is immense. In this situation perhaps an American or British postgraduate training may give a competitive edge. But I believe we should stop looking to the West. We have enough good teachers here and if young doctors want experience overseas they should go to China; it has found solutions to health problems that are very similar to ours.”

Should they come?

No systematic follow up information about how oveseas doctors fare when they return home is collected, and very little is known about what components of their training have proved useful and why. Many question the appropriateness of a British or any other Western style training for doctors who are returning to countries where both the nature of the medical problems and the means to deal with them vary so considerably.16

“I'm very ambivalent about the value of the ODTS scheme,” said Sir Ian Todd, who formerly ran the Royal College of Surgeons' scheme. “Exposure to high technology care may do little more than stimulate discontent if this form of care cannot be provided when they return home. I do, however, think that exposure to supportive care, especially good nursing care, is of value. Providing humane, patient centred care is not seen as a priority in some countries and I think the British example, in this respect, is a good one.

“In my view, we should move away from offering training at senior house officer and registrar level and provide more higher specialist training to a few, carefully chosen, well qualified, and experienced graduates who are going to be in a position to implement what they have learnt and teach others when they return home. I also think that we should be doing more to encourage British graduates to work overseas. More reciprocal exchanges between hospitals at senior registrar level should be set up and more practical, locally relevant, training programmes initiated and supported in the countries concerned. The view that a year working in a developing country is a wasted year is changing, but only slowly.”

Conclusion

Started with high ideals, inadequately thought through, and in some cases poorly administered, the Overseas Doctors Training Scheme has raised expectations that it has been unable to fulfil. Although the recent decision by the GMC and directors of the scheme to end individual sponsorship and process all applications through the colleges is a step forward - it should ensure a more uniform standard of trainees and more rigorous monitoring of their performance, it will greatly increase the workload for the colleges, and without appropriate funding it is hard to see how it can be implemented. Nor will it address the key question of whether these schemes offer worthwhile training or not. This can be answered only by independent evaluation.

Furthermore, improving the colleges' formal training schemes will not affect the larger pool of overseas doctors who come over independently. (A working party set up by the chief medical officer to review the arrangements and funding for overseas doctors who come to Britain is due to report soon.) That they do so entirely at their own risk is no grounds for complacency. At the very least, we should ensure that they are well informed, ideally before they come to Britain (see Lowry and Cope's article on p 1624). They need to know exactly what the rules are under which they are allowed to practise and for how long, and most importantly, they must be aware of the necessarily limited opportunities for postgraduate training. The value of delaying coming over to Britain until they have chosen a specialty and have sufficient experience in it to undertake higher specialist training should be emphasised. If a sizeable proportion of those who seek to come to Britain “faut de mieux” or merely to acquire exams or a rather non-specific “Western” veneer could be put off it may be no bad thing. At the same time, those who do come should not have to face undue frustration and disappointment.

If we believe that medical training is something that Britain does well - and this view is by no means universally accepted - we should promote it in a more coherent, controlled way. Better training opportunities should be provided for suitably experienced and the quality of their training monitored systematically. We should also offer more encouragement and support for British doctors to go overseas, both to widen their experience and to contribute to well coordinated, appropriate training schemes for overseas doctors in their own countries.