International Medical Graduates (IMGs)

IMGs in Acute Medicine

International Medical Graduates (IMGs) comprise an increasingly important part of the NHS workforce (1). They are doctors whose primary medical qualifications are from outside the UK. Their usual route of entry to the GMC register is via passing a license exam called PLAB or via obtaining GMC-accepted postgraduate degrees like MRCP. They can also get license to practice in the UK via the ‘GMC sponsorship route’ where they are sponsored to GMC registration via an approved GMC sponsor - a list of which can be found in the GMC website.

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IMG Evaluation

The routes of entry to the GMC register mentioned above evaluates an IMG’s overall competence to work safely in the NHS but does not automatically prepare them for daily life and work within the NHS micro and macroenvironment. There is a large amount of evidence in the existing literature which depict the struggles IMGs face when they start working in UK which, among other things, include a lack of familiarity with the healthcare system within NHS, difficulties of adapting to a new country and a new healthcare system, socio-cultural differences, language barriers, being subject to racism, bullying and unfair discrimination at work (2), suboptimal career growth and disproportionately higher financial difficulties. IMGs also suffer from a higher proportion of harsh and adverse outcomes when subject to complaints compared to local UK graduates(3). It is therefore not a surprise that IMGs suffer from differential attainment, something which is exemplified by the fact that they often fail to progress in their careers at the same rate as local UK graduates (4). All these go a long way to adversely affecting the mental health and wellbeing of IMG doctors (3).

Supporting IMGs

In view of the above, with a significant portion of the acute medicine workforce in the UK being composed of IMGs, it is imperative that all acute medicine departments employing IMGs are aware of the above mentioned struggles. It is also important that these departments are equipped with the guidance on how to best support the IMGs within their departments and help them reach their maximum potential. This will also ensure that IMGs are equipped with the right degree of support so that they can provide high quality care to their patients in a new healthcare system.

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Helping IMGs Settle

Below are a few suggestions on what may be done to help IMGs settle into a life in UK and work within NHS in a smoother manner, minimizing some of the adversities mentioned above and helping them maximize their potential(5):

Pre arrival support

IMGs can be equipped with some vital information about life in the UK and about their work in the NHS before they arrive in the UK. This can go a long way to ensuring that they have a smoother start to life in the UK. This can involve sending them information about how to rent accommodation, how to open a bank account, information about their hospital, about the transport system(both local and national), council tax, etc.

This are information that is taken for granted by people who have lived in the UK for a long time but are still information without which settling into the UK can be a very difficult process.

A structured Shadowing Period

IMGs, when they first come to the UK, find it very difficult to adjust to an entirely new healthcare system. This may be mitigated via providing them with a structured shadowing period during which they are supernumerary.

The primary purpose of that shadowing period is to allow the IMGs to get acquainted with the NHS micro and macroenvironment and learn about how to carry out the daily jobs of a doctor in their workplace.

This shadowing period works best if its duration is around 4-6 weeks and is structured in a manner where there is a well defined checklist to guide the IMGs on what to ensure or achieve by the end of their shadowing period.

An Enhanced Induction Programme

All IMGs new to UK should receive a bespoke induction catered to their unique needs and addressing the unique challenges IMGs face. This enhanced induction should include information about NHS, their hospital trust(for e.g the hospital hierarchy, the interspecialty referral pathways, information on the wider MDT and how they work within the hospital, library services, etc), career pathways, appraisal and revalidation, how to make use of their e-portfolio and about the various types of workplace based assessments, induction to the hospital IT systems.

Ongoing career support

With regards to this, all IMGs should have the following:

  1. A well defined pathway for career progression(for e.g progressing from SHOs to registrars to SAS grade after gaining a defined amount of experience and competence)
  2. Access to a clinical and educational supervisor and receive appropriately tailored supervision based on their unique needs
  3. Access to a regular teaching programme tailored to meet their own learning needs
  4. Opportunities to take up teaching/leadership/management roles within their workplace.
  5. Access to peer mentoring opportunities in a formal structured manner, best if given by people who have walked the same path as them and succeeded in navigating some of the same difficulties they face.

Pastoral Support

Apart from the difficulties in their workplace, IMGs also suffer from a lot of non clinical difficulties due to having to transition to a different country and an entirely different healthcare system.

As mentioned above, this can lead to significant cognitive difficulties and negative cognitive feelings. This can be mitigated by providing the appropriate degree of pastoral support, and there must be a clear plan within the department/trust they work on how this pastoral support may be delivered in a structured formal manner.

An example of a checklist, taken from the Specialist Medicine CMG at University Hospitals Leicester, is given below:

By the end of shadow period, a newly starting IMG in NHS should have ticked off the following:

    1. Received a full and signed copy of their contract
    2. Received the pre arrival information pack from Dept. of Clinical Education and the chief registrar, Specialist Medicine.
    3. Attended the GMC welcome to UK practice workshop and completed the NHS national induction package mentioned earlier.
    4. Attended a one full day enhanced induction information workshop
    5. Completed all their UHL Helm(mandatory e-learning) Projects
    6. Able to operate all the IT software used for patient management in a proficient manner
    7. Received their Horus/JRCPTB E-portfolio
    8. Shadowed a set of evening on calls(if your job would involve working on calls)
    9. Shadowed a set of night on calls(if your job would involve working on calls)
    10. Have a designated clinical and educational supervisor
    11. Have met with their Educational Supervisor and agreed on a Personal Development Plan based on SMART objectives. A guidance of other things that would need discussion at the initial meeting(s) with the ES can be found in the Appendix 4 section of the following guidance:
      https://www.e-lfh.org.uk/wp-content/uploads/2022/06/Welcoming-and-Valuing-International-Medical-Graduates-A-guide-to-induction-for-IMGs-WEB.pdf
    12. Registered for a Medical Indemnity Coverage
    13. Booked for an ALS course
    14. Joined the UHL Official Trust Grade whats app account(optional but very useful)

Resources

In addition to above, there are a number of resources which has been published nationally which can guide the acute medicine departments throughout the country on how to best support their IMG workforce.

For example, the GMC, in conjunction with NHS England and Improvement, BMA and other organizations, has put together a useful guide called ‘Welcome and valuing international medical graduates’(6) which is a valuable resource to guide trusts on how their IMG workforce can be best supported when they first start working in NHS.

The British Association of Physicians of Indian Origin (BAPIO) has also released the BAPIO LED Charter which focuses on the needs of locally employed doctors, but also stresses on how a majority of the LED workforce in UK are IMGs sharing some of the same struggles and challenges as the wider LED workforce.

In addition to the information above, below are some useful documents that an IMG can look into to provide them the information they need to settle into a career in the NHS:

  1. Charter for Locally Employed Doctors in the UK NHS by BAPIO SAS and LED Forum
  2. NHS Induction Programme for International Medical Graduates
  3. Welcoming and Valuing International Medical  Graduates: A guide to Induction for IMGS recruited to the NHS
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A career in Acute Medicine for an IMG

IMGs have main 3 routes into a career in acute medicine: 

They can start at an SHO level in NHS and then apply to get into IMT(internal medicine training). They will need to have the CREST form signed by a consultant whom they have worked with for at least 3 months within 3.5 years of the start of the IMT post.

They will need to have at least 12 months of experience post foundation year 1 equivalent training (12 months experience post internship in other countries) and must have a valid ALS and a valid visa to work in UK by the time they start in post as an IMT doctor - the visa will be supported by a Certificate of Sponsorship (COS) from NHS England.

After 3 years of IMT training, during which they can enhance their CV in acute medicine, they can apply for an ST4 training number in acute internal medicine and go through a 4 year training to earn a CCT in Acute and Internal medicine.

They can pass their MRCP exams and directly apply for an ST4 training number in acute internal medicine and train for 4 years to earn a CCT in acute internal medicine. In order to apply directly for an ST4 training post, they need to have the following:

  1. An Alternative Certificate to Enter Group 1 Higher Specialty Training Form(often referred to as Alternative IMT3 competence certificate) signed by a consultant with whom they have worked for at least 3 months within the last 3 years from 1st January of the year of the ST4 post start date. That consultant must also have worked in the NHS within the last 5 years.
  2. At least 4 years of experience post their foundation year 1 equivalent stage(i.e. 4 years post internship)
  3. A valid ALS
  4. A valid working visa by the time they start their post(the visa will be supported by a COS from NHS England).

The Portfolio Pathway: IMGs can continue to work in acute medicine without getting into training and can pass their MRCP exams. They can step up into a role as registrar unless already doing so, and then after 2 years of experience as a registrar in acute medicine, move into an SAS role in Acute Medicine. They can get more experience as an SAS doctor and eventually have the following options:

  1. Get a job in the GMC Specialist Grade where they work in similar capacities as a consultant
  2. Get a job as a locum consultant in Acute Medicine in a particular hospital
  3. Over the years, train themselves in the same way as they would be trained if in a training post, gather evidence on various aspects of their training and then apply to have their name in the GMC specialist register via the Portfolio Pathway (formerly known as the CESR pathway). Once their application is successful, they can work as a consultant in acute internal medicine in the same way as someone who has got CCT in acute internal medicine.

It needs to be kept in mind that compared to the other routes, the portfolio pathway is often regarded by many as one of the more difficult routes to become a consultant.

References:  

  1. GMC. The state of medical education and practice in the UK - The workforce report. London 2019.  
  2. Jalal M, Bardhan KD, Sanders D, Illing J. International: Overseas doctors of the NHS: migration, transition, challenges and towards resolution. Future Health J 2019; 6:76-81. 
  3. Chakravorty I and Latheef A. Charter for locally employed doctors in the UK NHS. BAPIO SAS and LED forum. 2022.  
  4. Pattison J, Blow C, Sinha B et al. Exploring reasons for differences in performance between UK and international medical graduates in the membership of the Royal College of General Practitioners Applied Knowledge Test: a cognitive interview study. BMJ Open 2019; 9:e030341. Doi: 10.1136/bmjopen-2019-030341.  
  5. RCP Commentary Magazine October 2023 Edition 
  6. Health Education England. Welcoming and valuing international medical graduates. HEE, 2022