Readers of Urology News will be familiar with descriptions of overseas visits by UK-based urological trainees, but it is sometimes beneficial to reflect on the experience of international medical graduates (IMGs) who elect to come to work and train in the UK. Colchester has had a fellowship scheme for overseas surgeons for over a decade. In this article three urology trainees describe their recent experience; this may result in many of us reflecting on how fortunate we are in the NHS and may increase awareness of the challenges faced by trainees coming to work in the UK.
I completed my MBBS in 2010 from the oldest medical school in Asia, the Medical College and Hospital, Kolkata and four years later, I completed my master’s degree (MS) in general surgery from the same institution.
I initially started working in the private sector but soon developed an interest in endo urology and decided to further study urology. In 2017, I finally passed the national specialty entrance exam for urology and joined Muljibhai Patel Urological Hospital at Nadiad, which is arguably one of the best urology teaching centres in India. I also completed the MRCS.
After completion of my urology theory examination in December 2019 there was a long pause due to the COVID pandemic when my practical examination was withheld for an undefined period of time. My country was in lockdown, my training duration was completed, I had no job and I could not claim to be a trained urologist as my practical examination was outstanding.
Thankfully, I had registered myself at the site https://trac.job.com/ that revealed job opportunities for urologists in the UK and I was appointed as a fellow / registrar at Colchester General Hospital in May 2020.
My urology practical examination was finally completed in September 2020 and my job in the UK was then confirmed.
What was your first impression about the job?
The advertisement mentioned a rough schedule of a full day of theatre, an on-call night followed by a day off, a flexible cystoscopy clinic, outpatient work and admin sessions. It also mentioned a 1:7 on-call rota. The weekend on-call schedule was clear to me, but I thought the 1:7 rota would only include the weekends. I was not aware that in the UK there is also weekday on-call as in India we were always available for our unit’s patients during office hours.
I was a bit sceptical about the acceptance of my urological knowledge and training in the UK but I liked the proposed timetable which was way less hectic than the usual schedules back in my country and I took a leap of faith. Regarding the opportunity for surgery, I was sure the consultants would not allow me to do cases independently, but I weighed this against the financial benefit.
What are the differences from healthcare at home?
In the UK, there is a fixed time for each patient in the clinic and hence there are a fixed number of patients; in India, the number of patients seen in a clinic is much higher. At my urology training hospital, the outpatient clinic also had a one-stop protocol; if a patient came in the morning by the time the patient went home, he or she will have a diagnosis. We had the facility to cover everything including blood tests, imaging (urethrogram, cystogram, ultrasound, IVU, CT), functional tests (flow rates and urodynamics) and even an anaesthetic check-up in a single day. I wondered why the UK did not have such a set-up.
Regarding theatre, the protocol is more or less similar. I liked the initial team briefing at the start of the day; interestingly anaesthetists don’t seem to like surgeons to be in the theatre while they are inducing the patient which is markedly different from my country.
Electronic medical records were not new to me as my training institute was paperless but administrative sessions were not allocated at my hospital; there was an expectation that clinical admin would be managed with time. The concept of hours of work is also vaguer in India and I regularly used to work more than the scheduled timetable.
I also found the advanced nurse practitioner concept innovative and very helpful.
What are the challenges?
As an outsider my first challenge was to understand the local culture, the way people talk, and their expectations which are different everywhere. I soon recognised I needed to be part of a system that was serving the local people rather than a part-time worker and I needed to work as part of a team, understanding my colleagues’ work patterns and ways.
The next challenge was to prove my worth. My consultants did not know me, and it takes years to gain confidence. Naturally, people might be less sympathetic to my faults and could easily point a finger at me. Hence, even simple things can cause me stress and I know stress can lead to silly mistakes. Happily, this has not been an issue so far.
Over a period, my next challenge will be career progression. My logbook and my degrees are not acceptable here and I recognise career progression may be difficult. I need to incorporate myself into a training programme as I could easily see myself in the same post after five years. In a nutshell, I need to bend myself with the wind with fewer margins of error and potentially there may be difficult future prospects.
I graduated from Mansoura University, Egypt in 2003 and spent one year as an intern in the university hospital. I then started my post-graduate career in 2005 as a resident doctor, completed my master’s degree in urology in 2010 and was promoted to urology specialist in 2011.
For financial reasons, I then decided to move to Saudi Arabia and worked there as a urology registrar in two hospitals for about six years. I was able to complete the FRCS(Urol) in 2018 and relocated to the UK in 2019.
I decided to move for many reasons: a move would hopefully help me in my career and importantly would allow my children to be raised and educated in the UK with better future opportunities for them.
I obtained a GMC license to practice after completion of the Occupational English Test (OET) in 2018 and I then applied through NHS jobs website for my current position in Colchester Hospital.
I quickly learnt that there are many terms for a middle grade post in the NHS (clinical fellow, speciality registrar, speciality doctor) and there are many different salaries. This caused me some confusion and worry, as I was aware that once you take a salary within the NHS, it would be very difficult to change even if you moved to another trust.
Some colleagues advised me to start with a clinical fellow post to get more training and to understand the NHS system better; then search for a permanent post later.
Comparison to healthcare at home
This was my first experience of a western country and I felt different and a complete stranger. I noticed that the working hours here are much longer than in Egypt and Saudi Arabia and although the hours can lead to fatigue, time spent at work helps integration into the system.
Compared to Egypt, hospital equipment and management are far more advanced in the UK. In Saudi Arabia, the equipment and hospital establishment are very similar but the staff are certainly more skilled in the UK and there is much more of a patient load here.
What I soon realised was that I would need to gain specialist registration with the GMC to be able to train in a subspecialty within urology. It was also clear to me that I could easily get stuck in a service job at a mid-grade level.
Specialist registration is clearly the big challenge for me. I applied for a training programme but was of course, rejected, as there are many requirements, including audit and research to which I have had no previous exposure. The Certificate of Eligibility for Specialist Registration (CESR) path seems to be the sensible way forward.
During a visit to a well-known UK reconstructive centre, I was amazed with the balance between impressive work and lifestyle, which led to my application to the UK. I applied for 20 posts and was shortlisted for 10 and then received offers from three hospitals. Following discussion with friends who had worked in the NHS, I followed their advice to start in a medium sized general hospital to allow integration into the system.
Why the UK?
Western citizenship and a passport are, of course, the target for dreamers. Why? World changes, instability, corruption and safety issues in the developing world are the main drivers. The OET language exam is a game changer and if successful, many pathways are open. The Professional and Linguistic Assessments Board (PLAB) test is a straightforward and quick way for new graduates but the Royal College exams (e.g. MRCS or the international FRCS(Urol)) are an alternative for surgical trainees with clinical experience. Direct sponsorship or the Royal College sponsorship scheme are more appropriate for an experienced urologist but my advice would be to first secure a job.
The immigration pathway for doctors entering the UK is clear for approximately six years with a tier two visa. In the USA where I spent five years, doctors will usually visit for a year to establish their connections and gain research and clinical experience. A residency will take about five years on a non-immigrant J1 visa with a requirement to return to their home country for two years after residency.
Alternatively, post residency, immigrant doctors in the USA might accept three years’ service in an underserved area on an H1 visa, followed by a green card application. If the IMG is lucky enough to find a job, he or she may obtain a green card and apply for citizenship after five years but the journey to citizenship for IMGs in USA is almost triple the length compared to the UK.
One of the major advantages in the UK is that you do not have to be appointed as a consultant from the national training system, as completing CESR requirements can lead to an equivalent specialist registration. Widespread consultant availability in the NHS is of course another very positive factor.
I have a research background and although UK hospitals do not generously fund research, research experience is certainly appreciated, and annual projects and audit are requirements for appraisal. Research in the UK is targeted towards helping patients, while in the US, research can be influenced by financial investment and big business plans.
Work life balance
Protected after work hours and generous annual leave allowances should not be underestimated in the UK; US residents could start at 4am and return home at 7pm while a UK registrar will generally stick to the 40-48 hours in a standard duty week. Although UK consultants are not as well paid as those in the USA, I am convinced that money is useless if you do not have enough time to enjoy life.
Free and reliable education is also a big advantage to working in the UK and university fees are less than in American universities with a comparable level of education. European universities are even cheaper and readily accessible from the UK.
Distances within the UK are small and the countryside is easily accessible from city centres and for the price of a single visit to Egypt from the USA, I can plan for three visits a year from UK.
How healthcare is different
The healthcare system is somewhere in the middle between the US and Egyptian systems, the service is not fully digitalised like the USA but is free like the Egyptian national system with a lot of private practice. The quality of the service is comparable to the American system, and consultant pay is midway between Egypt and the US.
One of the big advantages for UK practitioners is that the GMC and NHS trusts will support their members and private medical practice insurance is available for a reasonable cost.
Medical practice in the UK is focused on the patient’s best interest and based on recent guidelines and evidence and importantly, private health insurance companies have no role in determining the service provided. The drawback of this free health service is of course the long waiting list.
Visa, driving licence application, and banking are digital, which helps enormously with arrival.
I felt London was similar to Cairo where you can find opposites in one place, modern towers beside ancient buildings and clean civilized areas beside homeless-occupied subway stations. In London, you can sample the world’s cuisine in a week. I was joking with my family that if Londoners spoke Arabic and drove on the left side, it would be Cairo. To summarise, I felt at home.
Overseas fellows offer huge advantages to individual NHS hospitals and indeed the future provision of urological care in the UK. The diverse variety of trainees that the urology department in Colchester has encountered over 10 years has enriched the consultants as trainers and we feel very privileged to work with these young urologists who have given up so much to pursue their dreams.
I am grateful to Krishnendu, Hani and Ahmad who have generously shared their motivations and experiences integrating into the NHS. Not only do they give a fascinating insight into health practices in other countries and continents but they also highlight the challenges and barriers that overseas trainees overcome to pursue their careers. Thank you for sharing your stories.
Katie E Chan, Section Editor.