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LettersOverseas Doctors Training Scheme Opportunities for training are limitedEDITOR, - I wish that Tessa Richards had reconsidered the title of her article, "The Overseas Doctors Training Scheme: failing expectations."1 In the article she correctly identifies that the faults lie not so much in the scheme but in the constraints within which it operates.Why can we not meet the demand for posts? The royal colleges have no power to make appointments. We have to compete with a large pool of experienced, overseas trained, doctors based in Britain who have local referees and are available for interview. British surgeons prefer to select from these rather than appoint someone arriving from abroad "sight unseen." If a single trainee from the scheme disappoints them they determine never again to employ a trainee offered by the college. Why are expectations often unfulfilled? I recently visited southern India and met enough excellent trainees to fill all our requirements for a year. Unfortunately, Britain has a limited capacity to offer training to all the trainees who wish to come. This is not the fault of the scheme. We should be proud that our standards and training are still prized. How can we improve matters? I believe that the Department of Health and the General Medical Council should cooperate to reduce the floating pool of overseas graduates who are merely filling service needs and no longer receiving training. Some of those with rights of residence deserve staff grade posts to give them stability, which would free more training posts. I believe that awarding full registration and rights of residence to doctors who have not been in approved career training posts raises expectations that cannot be fulfilled as these doctors are condemned to second class status. All overseas doctors who come for training should be placed under the aegis of a royal college so that they can be guided and counselled, whether they come as sponsored trainees or gain limited registration by passing the Professional and Linguistic Assessment Board's examination. This service would need to be funded by the Department of Health as the royal colleges could not fund it. What of the positive aspects? Most of those who join the scheme arrive with an approved post awaiting them. They do not need to sit the Professional and Linguistic Assessment Board's test or take unsuitable posts to gain British referees. They are supervised throughout their training in Britain. We cannot, and should not, attempt to offer a full training: this is best acquired in the place where they will practise. R M Kirk
A successful example EDITOR, - The articles by Tessa Richards1 and Stella Lowry and Heather Cope2 were well researched and much overdue discussions on a matter on which hardly any discussion has taken place to date.3 They gave details of training schemes for overseas doctors and were to the point on their shortcomings. Any system set up on a nationwide basis will have problems, as does every new scheme, but we should be using them to fine tune the system for it to work successfully. In my own experience and in my hospital and anaesthetic department, the Overseas Doctors Training Scheme has been an unqualified success. Over the past seven years I have kept closely in touch with senior professors and consultants in the leading teaching hospitals in the Indian subcontinent and have made regular visits to lecture and discuss current developments and practices in anasesthesia. I also formally interview prospective candidates who have been initially shortlisted by their consultants. From the time I return, our human resources manager sets the ball rolling on the necessary paperwork. This then sits on file until a suitable senior house officer vacancy is imminent. From that point onwards it takes a maximum of two months to complete the formalities to get the selected doctor in post. To date there have been a dozen such appointments. They have all been of the highest calibre. They usually obtain their parts I and II of the anaesthesiology fellowship within two years of being with us and their part III within three years. They then proceed to join the registrar rotation scheme as non-career registrars. Details of this system and successes were presented to the Royal College of Anaesthetists' adviser in postgraduate studies, who replied, "Yours sounds like the ideal scheme, which is to be encouraged elsewhere." Like most things in life, we get results commensurate with effort put in. It would be a shame to abandon the scheme when it can produce results of such mutual benefit. R Kavan
Feedback from past trainees will help EDITOR, - Stella Lowry and Heather Cope provide all the information that a foreign doctor wanting to train in Britain would need to know.1 We agree with Tessa Richards that the Overseas Doctors Training Scheme has not met the expectations of many of its participants.2 Most doctors on the scheme have already completed three years or more of structured training in their chosen specialties. The same is true of doctors who come to Britain through independent arrangements. These doctors are looking for jobs that give them experience at the level of senior registrar or above; instead they end up doing senior house officer or registrar jobs for a few years, which do not give them the specialist training they hoped for. The present system seems to force them to repeat their basic training again in Britain. If the royal colleges could develop a scheme of fellowships lasting one or two years and offering higher specialist training to these well qualified doctors it would further the doctors' careers in their countries of origin. Otherwise the number of "stuck doctors" will gradually build up. Short term, concentrated high level training would also help to reduce the waiting lists for the overseas doctors training scheme. It would be useful to collect some systematic feedback from the overseas doctors who return home regarding the usefulness of their training in Britain. Perhaps the royal colleges should carry out a questionnaire survey of doctors settled in their native countries. This information could be used to formulate the changes in the overseas doctors training scheme that are necessary to reduce the mismatch between expectations and reality. The needs of overseas doctors from different countries vary widely - for example, obtaining the MRCP or FRCS is no longer a priority for Indian doctors wishing to rejoin their state or national health system. These degrees are no longer registrable as postgraduate qualifications in India; instead Indian doctors would prefer to obtain some higher grade, practical training to supplement their experience. G P Rao, N P O'Donnell, G Jyothi
A marriage of convenience EDITOR, - The Overseas Doctors Training Scheme is unique in that Britain and overseas doctors are both purchasers and providers - thus requiring both to understand each other's needs.1 We would like to highlight some areas in addition to those outlined in Tessa Richards's pragmatic and overdue article.2 Firstly, there is a common discordance between the priorities of overseas doctors and those of clinical tutors, who, having appointed "unknown quantities," expect them to successfully take Part I examinations to allow progress to registrar posts. The examination thus becomes a rite of passage, which it is clearly not designed to be.3 Also, not many are aware that, although being by far the largest contributor of overseas doctors, India does not recognise British postgraduate degrees. Furthermore, few appreciate the enormous career difficulties faced by doctors returning to their home countries after gaining higher training and qualifications in Britain.4 Secondly, if Britain needs "overseas doctors to fill junior posts, especially unpopular ones" and a prominent view is that higher specialist training should preferentially be provided to "a few, carefully chosen, well qualified and experienced graduates," it will be imprudent to turn a blind eye to the fact that research will be very high on the agendas of the majority of such candidates.5 Apart from personal dissatisfactions inherent in such situations, those aiming at higher degrees also face substantial registration fees and the hurdle of convincing a supervisor to accept an overseas doctor without a British postgraduate qualification. Thirdly, despite the published faults of the scheme, the "bad apple" coming through this marriage of convenience is the exception to the rule, although it will be naive and farcical to presume that every overseas doctor comes here only with the altruistic motive of "taking back" skills learnt in Britain. Most have multiple and varied academic and personal reasons - ranging from broadening intellectual horizons to looking into the potential advantages and disadvantages of international migration. In that context, it is rather unimportant to the overseas doctor whether Britain has adequate indigenous manpower resources for junior NHS service commitment posts. Finally, though there is no immediate concern that Britain will be unable to temporarily import such medical expertise, there is also no guarantee that future applicants will not look at centres of excellence in other countries for higher training. N Gandhi, P Johari, N Purandare
A scheme for filling unwanted jobs EDITOR, - Heather Cope and Stella Lowry give an impression that training for overseas doctors in Britain is set up simply.1 The rules have been changed to meet the "overall requirement" by the health service2 and are tightening up. In a few years there will no longer be any shortage of doctors and this so called "training scheme" will end up on the rubbish heap. The postgraduate training of overseas doctors in this country is a real shambles, more appropriately called a scheme of filling unwanted jobs. At the moment there isn't a structured scheme and it is hard to believe that this four year, permit free scheme could be tightened up without an organised programme.3 Overseas doctors come mainly from two sources. Those who are well connected and highly influential enter the Overseas Doctors Training Scheme; others take the tough, expensive, and challenging Professional and Linguistic Assessment Board examination. Either way the doctor then enters a common pool, competing with British and European graduates and other overseas doctors to obtain employment. Most, irrespective of their experience, find themselves as last choice candidates and end up occupying rejected jobs. I disagree that these doctors come to Britain with vague ideas; most of them compromise with the circumstances, especially those who have spent years of their savings to pass the PLAB examination. Even those who come through the training scheme are left to their own devices six months later. Unless they gain the higher qualification quickly, they end up doing inappropriate jobs for two to three years before working in a specialty, and soon they find themselves receiving short notice from the Home Office to leave the country. Cope and Lowry suggest that overseas doctors postpone their trip to Britain until they are eligible to take up a registrar post. I came to this country with two years of post-registration experience, with a view to training in neurology. However, I had to start my career in Britain as a house officer and worked in unpopular jobs for 18 months before finding suitable employment in neurology. If the four year permit free immigration rule has to be tightened, these doctors should have arrangements for an organised four year training plan before they enter the United Kingdom or once they have passed the PLAB examination. If left to their own devices, most of them would have to leave Britain before gaining a higher qualification, and they would take away an impression of being used as a pair of hands rather than trained. F Ahmed
Smaller, more relevant schemes are needed EDITOR, - Tessa Richards has highlighted many of the ways in which training schemes in the United Kingdom fail overseas doctors,1 but the disillusionment she has found is not universal and could be avoided. Many of the problems she describes - poorly structured training, difficulty in obtaining suitable posts, and emphasis on high technology Western medicine - arise in part because schemes are large, supervision is distant, and training goals are indistinct. Smaller schemes with clear, culturally relevant aims provide one solution. The training for overseas medical graduates in psychiatry in Manchester, for instance, accommodates 12 doctors from developing countries. Those accepted on to the scheme are guaranteed registrar posts in the North West region for two years, and the posts available to them are part of local postgraduate rotations. Their training includes an annual residential course on psychiatry in developing countries emphasising public health and administrative aspects of psychiatry, service provision, and health economics.2 Follow up data from doctors who have been through the scheme and returned home (almost all do so) confirm that these areas of knowledge, largely absent from conventional British training, are highly important in the posts that they occupy. After two years the trainees are required to take an examination in psychiatry in the developing world and to prepare a course of their own, one which they can use to teach doctors, health workers, or the public in their native countries about some aspect of mental health. Because the scheme is geographically and numerically restricted, close supervision of trainees' progress and problems is possible. We believe that an equivalent training could be designed in other medical specialties. However, an important shift in training philosophy would be required. The technical, hospital based medicine that some doctors want to learn when they come to the United Kingdom may not be a public health priority in their countries of origin. Successful schemes must learn to balance these competing needs. L Appleby, R Gater
Training in general practice is complicated EDITOR, - Stella Lowry and Heather Cope are certainly right when they observe that the rules governing the eligibility of doctors from outside the European Economic Area to train in the United Kingdom are complex.1 The situation in general practice is even more complicated than in hospitals. For a start, doctors have to have full registration from the General Medical Council to work in any capacity in general practice, including as trainees. Furthermore, trainee posts in general practice can be occupied by such overseas doctors only if they have the right to remain in the United Kingdom and wish to practise in the NHS, though there are indications in the rules that if an (overseas) sponsor can be found to pay the trainee's salary and associated costs, then permission for training may be given. Presumably the rules have been framed to take account of the fact that trainees in general practice are supernumerary and are not technically engaged to provide a service but only to do so as part of an educational experience. Other problems arise when a doctor with the right to remain in the United Kingdom has only limited registration and wishes to become a trainee in general practice. Under certain circumstances the General Medical Council may confer full registration, thereby allowing these doctors to become trainees. As a regional adviser in general practice I am frequently approached by overseas doctors seeking advice concerning training in and for general practice. I have been advised that such inquiries should be directed to the British Council. S E Josse
More visiting registrar posts are needed EDITOR, - In her article about the Overseas Doctors Training Scheme Tessa Richards has sidestepped the basic issue.1 It needs to be admitted that the scheme was motivated not by an impulse to train doctors for the Third World as much as by the desire to "achieve the balance" in the United Kingdom. Stated in plain terms, with the new regulations limiting working hours, there was a need for a very large number of middle grade doctors, such that could not all be accommodated in consultant posts four years later. The NHS required ready trained doctors to come in at the middle level, do the work for four years, and then return to their own countries without demanding consultant placements. With doctors coming from European Community countries the demand for such middle grade cover from developing countries is now falling. Even now, however, doctors on the scheme are preferred to doctors coming over from mainland Europe because they have a better knowledge of English and have had more specialised training (three years is the minimum, five to eight years is the norm) when they start in this country. Besides this, doctors from Europe do nothing to help "achieve the balance" as they have a right to demand consultant posts in Britain. Once this role of doctors on the training scheme is acknowledged, efforts can be made to improve the chances offered to them here - mainly by increasing the number of visiting registrar posts. The training provided under the scheme is exactly the same as for local graduates. Aspiring candidates must realise further that this training, although sound, is achieved at a very British pace - such that a British doctor trains for eight years while postgraduate training in most other countries takes four years. As regards the relevance of such training, it is up to individuals to translate it to the needs in their own countries. It would be pretentious for the royal colleges to assume to tailor this training to the needs of each overseas doctor's country of origin. J Puliyel
International fellows in general practice EDITOR, - Tessa Richards highlights some of the failures of the Overseas Doctors Training Scheme.1 For a number of reasons the Royal College of General Practitioners has not so far participated in this scheme. The college has, however, responded to the needs of several countries that are attempting to reoriente their systems of primary health care to serve more adequately the needs of the population. It has done this through the appointment of international fellows, in most instances jointly with the ministry of health of the country concerned. These fellows are appointed for some years and during that period will visit the country on two or three occasions each year both to participate in teaching and to advise on future developments. Recently the college has agreed to establish a system of accreditation for hospital and community training schemes in other countries. Unlike some other medical specialties, general practice or family medicine is in many respects culture specific. The college believes that the interests of the population are better served by helping other countries to help themselves, rather than by encouraging large numbers of doctors to spend some time in Britain learning the British way of general practice and seeking to obtain a qualification which is in many respects irrelevant to their own country's needs. This is very much in line with the comment of Sir Ian Todd in Richards's article. The college does, however, recognise that for a small number of experienced, highly motivated potential future leaders in family medicine in overseas countries a period of appropriate postgraduate training in general practice in the United Kingdom would be suitable. It is therefore discussing with the General Medical Council and other interested parties the best way in which these doctors' needs can be served. We can rightly be proud of the system of general practice and family medicine in Britain. We have some responsibility to try to ensure that its best features are made available in an appropriate way to countries that wish to emulate us. D G Garvie,
Plight of refugee doctors EDITOR, - The two articles discussing the intricacies of postgraduate training for overseas doctors in Britain provide a clear account of the many problems that arise.1,2 We wish to draw attention to the plight of doctors who are in Britain as refugees, who are not mentioned in either article. We realised the enormous adversity faced by this group when we took part in an orientation programme for refugee health workers at a college in north London. Many of the doctors in the group were highly qualified and experienced in their own countries and are now faced with a series of seemingly insurmountable hurdles before they can hope to practise their profession in Britain. They are often burdened with great personal losses, and their hopes of returning to medicine soon turn to despair. Books, tuition, and entry fees for the Professional and Linguistic Assessment Board's test are difficult to obtain. The required clinical placements are few. For older doctors in particular, the prospects of finding work once they have been registered are small. As refugees these women and men do not have an option of returning to their homeland or moving to another country. Much talent may be going to waste because the system weighs heavily against their making a contribution in their adopted country. More creative schemes are required to employ some members of this disenfanchised group of doctors. Can the profession rise to this challenge? J Rosenthal, S Singh
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