Should a UK postgraduate medical qualification be awarded to someone who has not worked in the UK?

UK medical postgraduate qualifications can be obtained outside UK^(1,2) without any work experience in UK. This is common knowledge among the medical profession around the world. This also a rather unique system since most postgraduate medical degrees and diplomas offered by institutions in many other countries require a period of training within their own countries. We were curious to know if the members of the public were aware of the ways by which UK postgraduate medical qualifications could be obtained and if it made any difference to their choice of a doctor to treat them.

A PubMed search did not reveal any such study about the public perception of doctor’s qualifications and its impact on consumer/patient’s decision making.

Our objective was to find out:

1)  If the public knew that UK postgraduate medical qualifications could be obtained outside UK

2)  If the public knew that UK postgraduate medical qualifications could be obtained without any work experience in the UK

3)  If the public knew that UK postgraduate medical qualifications could be obtained outside UK and without any UK work experience would it make any difference in their choice of a doctor if they needed medical care.

150 members of public in Kuwait from a similar social class and educational background were given questionnaires in either English or in Arabic. Questions were designed in sequence as per the objectives defined.

We found:

53% were not aware of the terminology of UK qualifications such as FRCS/MRCP etc

75% were aware that doctors with UK qualifications were practising in their city

72% would prefer to see a doctor with UK qualifications if they had a choice

50% thought that a doctor with a UK qualification would have a higher level of knowledge

45% thought that a doctor with UK qualification would have higher skills

85% said that if they were consulting a doctor holding UK qualifications they expected to benefit from the doctors UK experience

54% expected a doctor holding a UK medical qualification to have worked in the UK

67% did not know that a UK postgraduate medical qualification can be obtained without ever working in the UK

79% said that if they were seeing a doctor with UK qualification and they had the choice they would prefer to see one who has UK experience as well

84% said that if they had a major problem that needs a specialist consultation they would prefer to see a UK qualified doctor who also has UK work experience.

Discussion

About half the respondents were not aware of the terminology of UK postgraduate medical qualifications, but three fourths knew that doctors with such qualifications were practicing in their city. The majority also said that they preferred to see a doctor who held UK postgraduate qualifications. Therefore we feel that it is in the interest of the medical fraternity in the UK to promote an increased awareness of the terminology of the UK medical postgraduate qualifications so as to enable patients to make a better informed choice in selecting a specialist medical practitioner.

However, half of our respondents did not expect a doctor holding UK postgraduate medical qualifications to have a higher level of knowledge or skills. But, interestingly we note that a majority would like to consult a doctor with UK qualifications. This suggests that there must be other intangible factors at work, perhaps ‘trust’, ‘glamour’, an ability to induce patient confidence and so forth which are inherent or implied.

An overwhelming majority said that when they consulted a doctor holding UK qualifications they expected to benefit from that doctor’s UK work experience. Two thirds of the patients did not know that a UK postgraduate medical qualification could be obtained without UK work experience. This suggests that patient’s expectations could be let down due to a lack of information and awareness of the way in which such qualifications are awarded. Perhaps, more seriously it is possible to speculate that some patients have the mistaken impression that doctors who hold UK qualifications have worked in the UK when that is not actually the factual situation.

An overwhelming majority of our respondents said that if they had a problem that needed specialist consultation they would prefer to see a doctor who had UK postgraduate medical qualification and UK work experience. We infer that lack of information prevents patients from making the choice that they would like to make. Our respondents were all from a more or less similar social background of an educated and middle class nature. It may be possible to assume that in the general population or in a population segment with lesser education, the awareness of such matters is likely to be much less while the expectations may be similar and hence prevents them even more from making a proper informed choice; sometimes, possibly a wrong choice.

In summary, our survey shows that in Kuwait some patients thought that when they consulted a doctor with UK postgraduate qualifications the doctor also had UK experience. Many patients did not know that UK postgraduate medical qualifications could be obtained without ever setting foot in the UK. Patients preferred to consult a doctor who has a UK qualification and UK experience. We conclude, that some of the patient’s expectations are not being met due to the way in which the award of UK postgraduate medical qualifications are made. We also feel that some patients could be misleading themselves into thinking that when they consult a doctor holding UK qualifications the doctor also had UK work experience when in actual fact that may not necessarily be the case.

One of our recommendations would be that UK postgraduate medical qualifications be awarded only to persons with UK work experience. Alternatively separate nomenclature could be used to indicate that the UK qualification was obtained without UK experience and/or training; the Royal College of Surgeons of Edinburgh has already started some movement towards such a practise by the award of SMRCS,⁽³⁾ etc. Perhaps doctors holding UK qualifications could be obliged to divulge their training information as a part of enhanced ethical disclosure, say in their reception or waiting areas of their office. The institutions awarding such qualifications could have information campaigns that inform the patient hence empowering them with the ability to make an informed choice.

The Americans do not seem to confer their clinical postgraduate qualifications to doctors who have not actually worked in the USA.

The survey was conducted in the year 2000, we are not aware if there have been any changes in the public perceptions and understanding on this matter since.

 

References:

1.  http://www.rcsed.ac.uk/exams/

2.  http://www.rcsi.ie/postgraduate_examinations/index.asp

3.  http://www.rcsed.ac.uk/content/aboutus/271200322229.aspx

  

Note: The above material is extracted from the following poster presentation:

A postgraduate medical qualification from the UK. What does it mean to the public in Kuwait? M. Hemadri and M. Purva. Hull York Medical School First Research Conference, Hull. 11^th February 2004.

©M HEMADRI

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Examinations for doctors - time to think differently

I wrote the article below in 2006. I was not blogging at that time so it just lived in my computer. When you read it please be in a 2006 frame of mind. The article 14, the new rules for surgical exit exam, the impeding new contracts for doctors especially for SAS doctors and so on.

Once you have read it, cross reference it to the recent GP exam results.

We need an end to the monopoly of examination providers for post-graduate doctors. We need a plurality of avenues to demonstrate knowledge.  Why should every university in UK not have a knowledge test for specialist doctors?

The link to the intercollegiate website cited in the article will not work, you may want to search their website for the current link or otherwise check with them.

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THE EXIT EXAMINATIONS: IS IT TIME TO HAVE A DIFFERENT THINKING?

The surgical royal colleges have decided to allow any candidate who is able to muster the references of two consultant surgeons to take the intercollegiate exit examination. The colleges would see this as a response to the changes in the rules that have happened due the PMETB to allow a fair opportunity to anyone who wants to demonstrate their proficiency in surgical knowledge. The General and Specialist Medical Practise Order that created the PMETB was passed in April 2003 and there have been wide consultations before and since. It has taken three years to arrange a new format which is likely to change again very soon, in view of the MMC reforms.

While it is clear that the 'standard of knowledge' should be the same for surgeons entering the specialist register one has to question if the actual examination should also be the same. Whether different formats for differing groups/sub-specialties were considered is not known. Whether any surgeons who are not in training were consulted before these changes is not known. If any of the 'mediated entry' candidates who have taken these examinations in the past were consulted is not known. A close look seems to reveal the need to have some radical, new and different thinking about who should take which examinations and who should offer them.

HISTORY OF WHO PASSED AND WHO FAILED

The point about consulting the past candidates is rather important. The evidence for the importance lies in the figures available in the Intercollegiate Speciality Boards website (http://www.intercollegiate.org.uk/html/results.html) where between 1998 and 2001 the overall pass rates in the intercollegiate surgical exit examinations was 70% for mediated entry candidates, 76% for type two trainees and 96% for type one trainees. We should keep aside the issue of mediated entry candidates for just a moment and look at the glaring difference of pass rate between type 1 and type 2 trainees. Most type two trainees worked to similar rotas in similar hospitals with similar consultants and mostly for similar number of years. Some differences do exist in their pathways such as type one trainees spending more time in teaching hospitals and type one trainees having experience in some research, while many type 2 trainees also have such exposure not all of them do. Opportunities for courses, learning etc are all similar. However, when it comes to examinations type 2 trainees did not do well. It begs many obvious questions, the foremost of which is why trainees with such similar pathways did not fare similarly at the examinations. If type 2 surgical trainees had equivalent training to type 1 trainees, as an admission to the examination implied till recently, why did they not do well? If we accept that the examination was a true reflection of their training and knowledge then was the process that selected them was wrong? If we accept that their pathways were not as similar as described here then why were they allowed into the examination on the basis of ‘end of training’ ‘exit’ examination? Knowing that type 2 candidates fared badly what changes were made to address that situation? If they were genuinely poor why were they selected into specialist registrar posts, if they continued to be poor why were they not stopped from progressing through their training which enabled them to take the examination?

When so many questions exist in the issue of type 2 registrars, there are even more for mediated entry candidates of the past and especially possibly for non-training post holding candidates of the future.

THE DEBATE IS INTERNATIONAL AND ABOUT THE FUTURE

The debate is not simply about the present UK based SAS doctors, FTTA, LAT and LAS posts who intend to take these examinations under the new regulations. The future also demands some answers. Some of the colleges have taken upon themselves to hold these examinations in many parts of the world. The demand for such examinations exists. Would the colleges allow non-training doctors from abroad to sit the intercollegiate exit examinations? This opens an even wider debate whether surgeons not in non-training posts from anywhere in the world would be allowed entry in to the specialist register partly on the basis of a test of knowledge that UK Royal Colleges offered. That is not to say that such surgeons should not be allowed but to wonder if the GMC, PMETB and royal colleges have the resources to probe the credentials of such candidates so thoroughly that the British public can be assured of quality in real time practise and not success in a paper work exercise. Perhaps the easy way out is to ‘rule’ on application, that the applicant is in need of further training, which is in reality will be difficult and expensive to challenge by overseas applicants.

INTENTION VS REALITY

The law in the form of the PMETB rules allows for various types of demonstration of knowledge, specifically to enable a variety of suitable candidates to enter the specialist register. The surgical colleges instead of taking the cue and innovating, have changed the entry criteria and the format to allow non-training surgeons to sit the same examination. Instead of exploring and enabling diversity that the law demanded the situation is now quite simply similar to tying the hands of a challenger and then putting him into the boxing ring. The example of an SAS doing excellent breast work for years taking the exit examination as an opportunity and achieving a predictable failure can be foreseen very clearly. To state that it is the responsibility of the candidate to ready themselves in all aspects before appearing for the examination sounds very reasonable but in reality very cynical. To then retrain the candidate due to a PMETB refusal or an examination failure and on the successful completion of 'training' and/or 'examination' only to be employed to the same job but possibly a higher title seems bad logic and an extreme waste of resources.

There is also a general perception that the current format of the new examination could be interpreted as being that of a different standard than the recently expired one. There is a suspicion that the goal posts are set differently in preparation for the MMC changes.

MONOPOLY

In the UK there is only one form of test of knowledge. There is only one body that provides it. This situation may be appreciated as offering uniformity. On the other hand it could also be considered as a monopoly of provision. The general view of monopolistic provision is that it is unhealthy. The intercollegiate format could also be perceived as cartelisation of sorts. The reality of a very small number of people involved in taking these examinations may prevent such a thought stream from developing into meaningful progress.

Surely the royal colleges have huge experience in designing examinations and though a challenge could devise a range of 'fit for purpose' examinations which would be of equivalent standards to enter the specialist register. The law allows it though does not require the colleges to do so. Coming from a different angle would it not be logical to wonder why a breast specialist has not taken a specific exit examination in breast surgery and so on? The urologist does.

More and more of assessments are being delegated and devolved to local deaneries who then sub-delegate to individual trusts and consultants in the form of in the work place assessments. As a logical futuristic extension some consideration may be given to decentralising the test of knowledge to be provided by a range of alternative providers. This may be not only a great market opportunity but also an opportunity to demonstrate leadership and vision, for universities and private educational systems to device such tailored high standard tests of knowledge as they have already done in the CME/CPD areas.

CONCLUSION

No one argues the need for good knowledge before entering the specialist register; it is no doubt a must. The entire debate is about the demonstration of that knowledge. The intercollegiate surgical exit examination is one of them but it is probably suited only for the current type one trainees. That examination's suitability for others including type 2 trainees and their derivatives, the future MMC defined ST post holders, SAS surgeons, MMC generated non-training post holding surgeons, overseas non-training post holding surgeons is unclear, though many will take it due to lack of alternatives. There may also be reluctance on the part of the ‘higher’ authorities to accept alternatives.

It is time to realise that 'similar' and 'equivalent' do not have to mean doing the same things or taking the same examinations. It is possibly the time to wonder about the paucity of alternatives to demonstrate knowledge. With the large increase in the number of medical students and the possibility of expansion of ‘consultant’ numbers, it is time for the good and great of the medical profession, though the surgical example is illustrated here, to lead in thinking, policy and practise rather than to react and respond as shown repeatedly with some of the glowing examples such as Calman, EWTD, PMETB and MMC amongst many others, with many issues arising from them still remaining unresolved.

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©M HEMADRI 

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