Time to accept responsibility

Laura Emery is an Academic Clinical Fellow working for the University of Sheffield in the field of medical education, specifically the experiences of international graduates in UK GP training.

Iam disappointed and infuriated to find that yet again one of my colleagues has failed the Recorded Consultation Assessment (RCA). I have worked with her before, she is competent, conscientious, and popular with patients, so why I ask? Immediately the uncomfortable answer surfaces: She is an international graduate.

We are given reassurances that the MRCGP exams are fair and unbiased,1 and it seems that since differential attainment within the RCA is no different to the Clinical Skills Assessment (CSA) that this has been deemed an acceptable exam.2 How can this be? I think we are too afraid it shine a light on this issue, worried about what might be unearthed. Instead papers are published comparing the Professional and Linguistic Assessments Board test (PLAB) scores with the MRCGP Applied Knowledge Test (AKT) and CSA scores, and the conclusions they draw? That perhaps international medical schools have lower standards, that their graduates just aren’t as good as those trained in the UK.3 This toxic message propagates so that when trainees are asked about differential attainment, they express their concerns about the standards of training of their international colleagues.4

We are too afraid it shine a light on this issue, worried about what might be unearthed.

Reading these articles, published in a high impact UK medical journal, makes me irate to say the least. Where is the acknowledgement of the responsibility of our postgraduate training? When international graduates sit the CSA or the RCA, they have been working in UK medicine for at least 2.5 years. The blame does not lie with our international colleagues, I would argue that it sits firmly at our feet as educators. But this failure to recognise our shortcoming is not unique in this area, in fact most studies looking at the challenges faced by international graduates fail to acknowledge the bilateral responsibility that includes the responsibilities of the new health system.5

During a meeting with colleagues, an experienced trainer reports how demoralised her trainee was after attending the regional international graduate induction. Immediately following the induction he came home, signed up to PassMedicine and booked and AKT exam course after being told it was likely he would fail the AKT because he is an international graduate.

Imagine the situation, you are new to the country, you have already had to prove your clinical competence by passing the PLAB exam, and have gone through the complicated and stressful process of obtaining a visa. You have registered with the GMC. You have been assigned a training number in an unfamiliar area and have had to find appropriate accommodation. Your relatives may be back home or in another part of the country. The NHS is an unfamiliar healthcare system, and you may not even be sure about what the role of a GP is within the system. You are expected to engage with learning in a completely new way, navigating portfolios and setting your own learning outcomes. All of this places you under significant pressure. You may already feel a loss of identity, a loss of social standing. And following all this, no matter how much experience you have in your home country, you are immediately told you are at high risk of failing your exams and not completing training.

We need high quality research into differential attainment ….. so we can identify where training is failing and what we can do to fix it.

Assuming and treating international graduates as if they are ‘less than’ is extremely damaging. We are systematically destroying the confidence and self-esteem of our colleagues. We are setting them up to fail. We are pretending to ourselves that this is their issue and not ours.

So what can we do? On a college level, there needs to be acknowledgement of this as a major issue. We need high quality research into differential attainment and the experiences of international graduates so we can identify where training is failing and what we can do to fix it.

Overall, however there needs to be a shift in attitudes. If you are training international graduates in your practice, please don’t assume they are ‘less than’ their colleagues. Take the time to ask them about their journey into general practice training both personally and professionally. Ask them if there are areas they are finding difficult to navigate, and offer support where it is needed rather than making assumptions.

Remember that the experience and diversity that our colleagues offer is to be valued, and it is the job of a training scheme to build confidence, not break it.



  1. College R. Final Report from Health Professional Assessment Consultancy on the 10-year external review of the MRCGP examination. 2017; (October 2018).
  2. Denney M, Wakeford R. MRCGP Annual Report [Internet]. Available from:
  3. McManus IC, Wakeford R. PLAB and UK graduates’ performance on MRCP(UK) and MRCGP examinations: Data linkage study. BMJ [Internet]. 2014;348(April):1–24. Available from:
  4. Woolf K, Rich A, Viney R, Needleman S, Griffin A. Perceived causes of differential attainment in UK postgraduate medical training: A national qualitative study. BMJ Open. 2016;6(11):1–9.
  5. Michalski K, Farhan N, Motschall E, Vach W, Boeker M. Dealing with foreign cultural paradigms: A systematic review on intercultural challenges of international medical graduates. PLoS One [Internet]. 2017;12(7):1–20. Available from:


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I agree with much of what you write, particularly around myths about learner deficits but also a significant focus on separate remedial educational interventions. Have you looked at ‘Culturally Inclusive’ teaching practices? For the individual educator this provides sound strategies and practical suggestions of how to adopt ‘inclusive pedagogies’. ‘

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