1

TABLE OF CONTENTS

TABLE OF CONTENTS.................................................................................................................2
INTRODUCTION........................................................................................................................... 5
ACKNOWLEDGEMENTS.............................................................................................................7
---- SECTION A --- POSTGRADUATE MEDICAL EDUCATION IN PAKISTAN...............8
AFTER PASSING FINAL YEAR (M.B.;B.S.).............................................................................8
THE HOUSE JOB......................................................................................................................... 8
THE FCPS PROGRAM.................................................................................................................9
The Different Specialties.......................................................................................................... 9
The FCPS-I Exam...................................................................................................................11
Timing Of The FCPS-I Exam And The “1-Year Delay”........................................................ 11
After Passing FCPS-I ............................................................................................................ 12
The Components of FCPS Training........................................................................................13
Clinical Skills Courses............................................................................................................13
The Dissertation..................................................................................................................... 14
The FCPS-II Exam..................................................................................................................14
THE DCPS PROGRAM..............................................................................................................14
PRACTICAL CONSIDERATIONS............................................................................................15
Clinical Exposure................................................................................................................... 15
Quality Of Training................................................................................................................ 16
Cost Of The FCPS Pathway................................................................................................... 17
Time and Money..................................................................................................................... 17
---- SECTION B ---- POSTGRADUATE MEDICAL EDUCATION IN THE UK..................19
THE NHS.....................................................................................................................................19
THE GPS AND THE SPECIALISTS......................................................................................... 19
BASIC AND HIGHER SPECIALIST TRAINING.................................................................... 19
THE DIFFERENT GRADES...................................................................................................... 20
The PRHO Grade................................................................................................................... 20
The SHO Grade...................................................................................................................... 20
The Staff Grade.......................................................................................................................22
Type I SpR Posts..................................................................................................................... 23
Type II (FTTA) SpR Posts.......................................................................................................23
Trust posts...............................................................................................................................25
Locums....................................................................................................................................26
THE MEMBERSHIP EXAMS....................................................................................................26
TERMS NOT ALREADY COVERED.......................................................................................30
MODERNIZING MEDICAL CAREERS – HOW THE SYSTEM IS CHANGING AND HOW OVERSEAS
DOCTOR WILL BE AFFECTED................................................................................................................ 32
Modernizing Medical Careers (MMC)...................................................................................32
Integrating The “Old” System With The “New” System....................................................... 32
The Foundation Programme.................................................................................................. 33
After The Foundation Programme......................................................................................... 34
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 How Will The Foundation Programme Affect Overseas Doctors?........................................ 37
THE SITUATION ON THE GROUND: SOME PRACTICAL CONSIDERATIONS.....................................39
The Job Situation.................................................................................................................... 39
Progression Of Overseas Doctors In The NHS...................................................................... 41
The Money Factor.................................................................................................................. 42
POSSIBLE ENTRY POINTS INTO THE NHS......................................................................... 43
PRHO/FY1..............................................................................................................................43
Staff/Trust Grade.................................................................................................................... 43
Consultant Grade................................................................................................................... 44
ENTERING AT THE SHO/FY2/BST GRADE..........................................................................44
House Job............................................................................................................................... 44
IELTS...................................................................................................................................... 44
The PLAB Exam......................................................................................................................46
Registration............................................................................................................................ 47
Finding a Job..........................................................................................................................47
HOW TO IMPROVE YOUR CHANCES...................................................................................48
Growing Your CV – The concept............................................................................................48
Growing Your CV – As a medical student..............................................................................49
Growing Your CV – As a house officer.................................................................................. 49
Growing Your CV – After the house job.................................................................................50
Growing Your CV – Upon entering the UK........................................................................... 52
Presenting the CV................................................................................................................... 54
The Job Interview................................................................................................................... 54
---- SECTION C ---- POSTGRADUATE MEDICAL EDUCATION IN THE USA............... 56

INTRODUCTION..........................................................................................................................56
Some Important Terms And Concepts.................................................................................... 56
How It All Started................................................................................................................... 57
How It Got Going................................................................................................................... 58
The Evolution Of The ECFMG Tests......................................................................................58
THE USMLE AND RESIDENCY APPLICATION PROCESS................................................ 60
Step 1...................................................................................................................................... 61
Step 2 CK................................................................................................................................ 62
Step 2 CS.................................................................................................................................63
A Word On Step 3................................................................................................................... 63
What Sequence Are These Exams Given In?.......................................................................... 64
APPLYING FOR A RESIDENCY..............................................................................................64
ECFMG Certification............................................................................................................. 64
Improving Your Chances........................................................................................................ 67
EXAMPLE OF A TIME-LINE FOR PLANNING THE STEPS................................................68
Step 1...................................................................................................................................... 68
Step 2 CK................................................................................................................................ 68
Step 2 CS.................................................................................................................................68
Step 3...................................................................................................................................... 68
ERAS.......................................................................................................................................68
The Reasoning Behind This Time-line....................................................................................68
THE VISA ISSUES..................................................................................................................... 69

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 The B Visas............................................................................................................................. 70
The F-1 visa............................................................................................................................ 71
The Visa Problem And The Step 2 CS.................................................................................... 72
The H1-B visa......................................................................................................................... 73
The J1 visa.............................................................................................................................. 74
CONCLUSIONS.............................................................................................................................77
A FUNDAMENTAL CHANGE IN ATTITUDES IS NEEDED................................................77
BE PROACTIVE AND DO YOUR OWN RESEARCH............................................................78
PLAN EARLY AND FOCUS..................................................................................................... 79
FACING LONG PERIODS OF STUDYING............................................................................. 79
DEALING WITH PERSONAL PROBLEMS............................................................................ 80
AND FINALLY….......................................................................................................................80
ABOUT STUDENTS' LEARNING FORUM..............................................................................82

4
 INTRODUCTION

This manual is a product of the Student Learning Forum (SLF), an organization of

students in Khyber Medical College (Peshawar), dedicated to improving the academic
environment and standard of our college.

I, Atif Rahman, started researching the material present in this manual in the summer of
2004 and am writing this very last section of the manual, the introduction, in the early
days of February 2005. This manual is being written in my capacity as a cabinet member
of the SLF and its Exam and Career Guidance Coordinator for the year 2004-2005. This
publication is being issued on a non-profit basis and is also available to download for free
online to those who cannot obtain the paper-format of this manual.

The need for such a publication was felt because it was generally recognized that most
students in their final year of medical college in our area had absolutely no idea how to go
about the next stage of their professional life. While most may have had vague hopes and
notions of going to the US or to the UK, few knew of the technical and, more importantly,
of the practical details of how to go about doing this.

This manual is aimed at all medical students, particularly the more senior ones – those
who are more likely to give serious thought to their future after medical college/university.
It is also aimed at junior doctors (i.e., house officers) and newly graduated doctors who
are wondering what to do next.

This manual gives practical and technical information about the three most common post-
MBBS options pursued by Pakistani doctors these days. The basic purpose of this
manual is to lay out these three different options for you, explain how these three different
systems work, and how you can go about entering the one you want. This way, life after
MBBS will be somewhat illuminated and this in turn will make it easier to plan ahead.

This manual does not tell you which of the three to choose, but merely provides all the
information about the three options you’ll need to make the decision yourself. Ultimately
you, the reader, are in charge of your own life and it is you who will be most profoundly
affected by the decisions you make for your post-MBBS career. This manual should be
seen as a source of basic information needed to make that choice an intelligent and
informed one. In other words, if after reading this manual, you decide to chose one option
over the others, you should have good reasons for doing so.

The manual was written on the basis of a lot of research. I met about a dozen doctors
personally, and corresponded with more than two dozen more over email. I read
hundreds of documents and finally, after finishing the first draft, had the manual reviewed
by doctors within the different systems to ensure accuracy.

PLEASE SEND US YOUR COMMENTS AND SUGGESTIONS.

This manual is not the last word on the subject-matter contained within it, but merely the
first edition of a work that will be updated annually. As the first edition is always the most
difficult to write, this manual does not explore the more uncommon post-MBBS routes
5
available to doctors, namely the career opportunities in Canada, New Zealand, and
Australia. It also does not discuss Master of Public Health (MPH), an apparently
promising post-MBBS option. These options will be included in the next edition, due in
March 2006, and will be dealt by my successor in the SLF.

In order to improve on the contents of the manual, we at the SLF need your feedback and
comments. Let us know if any aspect of the text was unclear to you. Report back on any
errors you have found and points you felt we should have covered.

Send your emails to: fractionsky@yahoo.com

This manual is a volunteer effort. All comments of support and encouragement will be
warmly received. If you have found this manual useful, please do let us know. Knowing
we’ve helped others is what keeps us going.

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 ACKNOWLEDGEMENTS

I would like to thank the following people for their advice, encouragement, and guidance.
This manual would not have been possible without their influence.

• Elitham Turya, consultant in child health, Trafford NHS Trust, Davyhume,

Manchester, UK.
• I am extremely thankful to Dr. Muhammad Zahid Saeed MRCS who proved to be, by
far, the most helpful doctor I contacted.
• Dr Jayaprakash A. Gosalakkal, consultant pediatric neurologist.
• Dr. Mohamed Arafa associate postgraduate dean and consultant orthopedic surgeon,
West Midland Deanery.
• Dr. Shaaz Maboob of the London strategic health authorities and workforce
development confederations.
• Dr. Ramesh Chelvarajah
• Dr. Peter Tun, associate specialist, neuro-rehabilitation medicine
• Dr. Irfan Kundi, MD whose faith and trust in me was touching - and whose character
and professionalism inspiring.
• Dr. Hashim Khan, MD for his help with the US visa issues and extensive review of the
US section.
• Dr. Nosheen Javed, MD, and Dr. Sairah Ahmed, MD for their extraordinary 3-day
USMLE seminar.
• Dr. Sajid Khan, MRCP of PIMS, Islamabad for his very accommodating nature.
• Dr. Zafar Iqbal, whose story is a source of inspiration to all those who know it.
• Dr. Mumtaz Shah, MD who explained the ins and outs of the Steps and helped
revolutionized the academic environment in the KTH library.
• And finally, a very special thanks to the tirelessly helpful Dr. Umesh Prabhu,
consultant pediatrician - of the British Association of Physicians of Indian Origin. His
example of selfless dedication to helping others is unique among all the doctors I
contacted.

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 ---- SECTION A --- POSTGRADUATE MEDICAL

EDUCATION IN PAKISTAN

AFTER PASSING FINAL YEAR (M.B.;B.S.)

After graduating from a recognized Pakistani medical college or university, a doctor is
given provisional registration by the Pakistan Medical and Dental Council, or PMDC as a
new doctor.

THE HOUSE JOB

The “house job” follows soon after the final year result and lasts for one year. It actually
consists of two separate house jobs that last 6 months each. The house jobs are offered
in all the major specialties, for example Medicine, Surgery, ENT etc… as well as the
subspecialties like Cardiology, Dermatology, etc… Of all the specialties on offer, the
Medicine and Surgery ones are the most competitive and allow only the best of each
graduating class.

Getting into a house job in the hospital(s) associated with your medical college depends
on the marks you’ve obtained in your final year. For example, currently in Khyber
Teaching Hospital, there are 40 medicine and surgery rotations offered first to the top 40
students of the graduating class. If some of those top 40 decline a medicine and surgery
rotation (6 months in medicine and 6 months in surgery), then the students below them in
the merit list are accommodated in their place.

There are also positions in medicine and surgery in the other teaching hospitals in
Peshawar, namely Lady Reading Hospital and Hayatabad Medical Complex. You are
also eligible to apply for positions in other hospitals in Pakistan, but it must be kept in
mind that hospitals affiliated with medical colleges/universities will give their own
graduates priority and give outsiders a place only when the house job positions are not
filled by their own graduates.

For those hospitals not affiliated with a medical college/university, the general criterion for
formulating a merit list is often an entry test.

When the house job is completed, the provisional registration becomes permanent and
the doctor is recognized by the PMDC as a Registered Medical Practitioner (RMP).

8
 THE FCPS PROGRAM
Upon finishing the house job, the doctor becomes eligible to pursue a specialization
training program called the FCPS. This stands for ‘Fellow of College of Physicians and
Surgeons’. The term FCPS is used loosely to refer not only to the system of post-
graduate medical training, but the exams needed to complete such training, as well as the
qualification itself. In other words after the house job, the doctor will enter the FCPS
system of training, will give the FCPS exams in the process, and when successful, will
attain the qualification of FCPS.

The term FCPS is used to refer to all the specialties. A doctor training and successfully
completing the training program in ENT will be called an FCPS just as a doctor
completing a training course in Medicine will be called an FCPS. This doesn’t mean
however that the FCPS training programs for the different specialties are the same - on
the contrary, the FCPS exams and training content are different for different specialties.

Regardless of the specialty, the FCPS exams consist of two parts: the FCPS-I and the
FCPS-II.

To enter an FCPS training program, the doctor must pass the FCPS-I exam. After the
exam, he will apply for training posts and take interviews to secure those posts. An FCPS
trainee is called a Trainee Medical Officer, (TMO) or a Postgraduate (PG). His training will
last for either 4 or 5 years, depending on the specialty. When his training period is over,
he will be eligible to sit for the FCPS-II exam, and if he passes it, he will be awarded the
qualification of FCPS – which designates him as a specialist in his field.

THE DIFFERENT SPECIALTIES

There are many specialties that the FCPS is offered in, although it must be kept in mind
when choosing to pursue a certain specialty that the number of training posts for that
particular specialty may be limited.

The major specialties are:

• Medicine and Allied

• Surgery and Allied
• Anesthesia
• Diagnostic Radiology
• Dentistry
• Gynecology and Obstetrics
• Ophthalmology
• ENT
• Pathology
• Psychiatry
• Basic Medical Sciences

9
In order to enter any of these specialties as an FCPS trainee, the doctor must have done
his house job in that specialty. He cannot, for example, do his house jobs in ENT and Eye
and then sit for the FCPS-I exam for Medicine. If he wishes to pursue Medicine (or one of
the Allied specialties), he must have done one of his house jobs in Medicine.

The Allied specialties for Medicine are:

• Cardiology
• Clinical Hematology
• Dermatology
• Gastroenterology
• Neurology
• Pulmonology
• Physical Medicine & Rehabilitation
• Clinical/Chemical Pathology
• Community Medicine
• Family Medicine
• Nephrology
• Nuclear Medicine
• Pediatrics

If you wish to go into one of the specialties allied with medicine, you can do your house
job in medicine and be eligible to enter the training program of a specialty that is allied
with medicine. For example, doing a house job in medicine (6 months) and then surgery
(6 months) will allow you to be eligible to pursue a Pediatric FCPS program. However,
when applying for such specialties (as a TMO), you must keep in mind the number of
available TMO positions available in that specialty and the location of such positions.
Information regarding the competitiveness of a specialty can best be obtained by asking
those senior to you in the hospital you wish to apply to. If for example, there are only 5
TMO positions available in Clinical\Chemical Pathology (for the whole province), you
should investigate the locations and availability of these positions and keep this
information in mind when planning your FCPS training. It is quite possible, for example
that a certain specialty is not available in your province.

The same principles apply to the specialties allied to Surgery:

• Cardiac Surgery
• Orthopedic Surgery
• Plastic Surgery
• Urology
• Neurosurgery
• Pediatric Surgery
• Thoracic Surgery

The period of training for Medicine, Surgery and Allied is 4 years. For the ‘minors’ like
ENT and Eye, it’s 5 years while Gynecology/Obstetrics is 4½ years. Every specialty has a
detailed prospectus with information regarding the FCPS exams for that specialty, training
10
requirements, dissertations, etc… Anyone interested in pursuing an FCPS training
program should obtain the prospectus from regional CPSP offices or from the central
CPSP headquarters in Karachi.

THE FCPS-I EXAM

The FCPS-I exam, in all the specialties tests knowledge in the basic sciences. It is a
single, 3 hour MCQ paper. The exam focuses on those sections of basic sciences that
are relevant to its specialty. For example the FCPS-I exam for Gynecology and Obstretics
will focus more on the Pelvis and Perineum in its questions of gross anatomy while the
FCPS-I exam for ENT will focus on Head and Neck in its anatomy questions. Similarly,
the FCPS-I contains questions from the other basic sciences (besides anatomy) that are
relevant to its own field besides containing general questions relevant to all specialties.

There is no negative marking in this exam of 100 questions - however the pass rate is
low, ranging from 8-30%. This is because the passing margin is set quite high at
approximately 80%, which means a candidate cannot afford to get more than 15-20
questions wrong.

The subjects tested in the FCPS-I exam are:

• Anatomy (Gross, Histology, Embryology, Neuro-anatomy)

• Physiology
• Pharmacology
• General and (some parts of Special Pathology)
• Microbiology
• Community Medicine (not a major subject, unless the specialty itself is Community
Medicine)

Specialty Related subject: Although clinical sciences are not included in the FCPS-I
exam, reading a specialty related book would help integrate the relevant basic sciences
information. For example, reading an ENT book for FCPS-I ENT exam would most
definitely be of some benefit.

TIMING OF THE FCPS-I EXAM AND THE “1-YEAR DELAY”

The FCPS-I exam is held 3 times a year. The dates for the exams are not the same every
year, but approximately in the time-periods mentioned below.

• February/March
• June/July
• October/November

In order to take the FCPS exam, the application to the CPSP must reach two months
before the exam date itself. So if a candidate wants to give the exam in February/March,
the exam application must be in the CPSP offices in December. In Khyber Medical
College, the house jobs currently ends in late January so submitting an application for the
FCPS-I exam for the February/March date is not possible because in December, the

11
candidate would not have finished his house job and will therefore not have elevated his
provisional registration to a full registration – which is an essential requirement for
eligibility to the FCPS.

This means that the candidate cannot appear in the February/March FCPS-I exam, but
will have to wait for 5 months till the June/July date. He will not be able to move forward in
his post-graduate training during those 5 months. Even if he gets a job as an RMP
somewhere, his work will not count towards his FCPS training.

Further, the delay is not of just 6 months, but it stretches out to one year. The reason is
that FCPS trainees are entered into training hospitals every June and January. Since you
are ineligible to take the exam in February/March, you will have to wait for June/July.
However, when you pass the FCPS exam in June/July, the interview date for new
trainees will already have passed and their training started. Therefore, if a graduate ends
his house job in January, he will only be able to sit for the FCPS Part I exam in June, and
will have to wait till the next January to start his FCPS training. There is, as a result a
year-long gap between the end of the house job and the start of the FCPS training.

There is one possible way to avoid this one-year gap. You can, as you near the end of
your house job obtain a statement signed by the administrative head of your hospital that
you will finish your house job in a few months time. You can use this statement in place of
your certificate of full registration with the PMDC in order to appear for the FCPS-I exam
in March. In NWFP however, the one-year gap will still apply because TMOs are inducted
into their FCPS training program only in January. Therefore, even if a house officer from
NWFP gives his FCPS-I exam in March (a couple of months after finishing his house job)
he will still have to wait for 8-9 months till January to start his TMOship. However, in other
parts of the country like Punjab, Karachi and Islamabad, TMOs are inducted twice a year
(in January and June) so a doctor from NWFP can choose to apply to a teaching hospital
those areas in the following June.

AFTER PASSING FCPS-I

After passing, you will apply for a TMO (Training Medical Officer) post in a certain
hospital. It must be mentioned here that not all TMOs are awarded the post. Every
province in Pakistan has a fixed number of TMO posts which it can give and if the number
of applicants exceeds the number of TMO positions available then some will be left out.
Such applicants thereafter can apply for non-training jobs in private or government
hospitals as Medical Officers. The pay, in private hospitals may be marginally higher for
non-training posts (although this is not always the case), but the downside of it is that the
experience will not be counted towards an FCPS degree.

As a result of the limited number of TMO posts available, in some parts of the country, the
induction of TMOs into FCPS programs may not be twice, but once a year.

12
THE COMPONENTS OF FCPS TRAINING
After you have secured an FCPS training post, you will begin your duties. It is generally
acknowledged that the workload for TMOs is very demanding, more so perhaps than for
junior doctors in the US and UK. In many hospitals, TMOs are given a lot responsibility for
patient care and management – with these responsibilities increasing as the TMO moves
forward in his training.

During the course of training, the medical TMOs must take 3 mandatory workshops while
the surgical ones must take 4. These workshops have to be taken within the first 18
months of TMOship:

• Computer and Internet Skills. Lasts for 5 days and imparts basic knowledge of how
to use computers and the internet. For those who feel they already have such skills,
there is an equivalence test one can pass to attain a certificate attesting to the fact.
• Research Methodology, Biostatistics, Dissertation Writing. Lasts for 5 days and
gives an intensive course on how to conduct research, how to interpret the data from
such research and how to incorporate these skills in a Dissertation (see below).
• Communication Skills. A 3 day course on effective communication techniques in
presentations, workshops and seminars.

These three workshops are mandatory for all TMOs regardless of their specialty and must
be taken within the first 18 months of training.

For the TMOs in surgery, an additional 3 day workshop on Basic Surgical Skills is also
mandatory – also to be taken within the first 18 months of TMOship.

These workshops cost Rs. 8,500 each except for the Computer and Internet Skills
workshop which costs Rs. 7,500. They are held several times a year.

(The workshops can be taken by any doctor, not just a TMO. This fact was mentioned in
the UK section of this manual to point out that such workshops strengthen an individual’s
CV as they are officially organized by the CPSP and therefore recognized abroad.)

CLINICAL SKILLS COURSES

These are non-mandatory courses lasting 5-7 days in which a group of senior doctors
volunteer to conduct a thorough revision of clinical examination procedures to candidates
who will soon be appearing for the FCPS-II exam (which contains a clinical examination
component). The course cost around Rs. 500 and are usually held some time before the
FCPS-II exam dates.

For those non-FCPS-II candidates who wish to add to their CV, it should be noted that
these courses are not formally organized by the CPSP, and as such will have limited
value to a doctor who is not an FCPS-II candidate. In other words, attending such a
course will not add appreciably to your CV in the way the CPSP-organized workshops
will.

13
THE DISSERTATION
To quote the FCPS Dissertation Instruction Manual, issued by the CPSP.

“Submission of Synopsis/Protocol on a chosen topic, its approval from Research

and Training Monitoring Cell (RTMC), CPSP, and preparing a dissertation,
acceptable to the College, is mandatory for all candidates aspiring to appear in
the FCPS II theory, clinical and oral examinations. In doing so, the CPSP aims at:

• Cultivating an inquiring mind in its potential specialists.

• Encouraging in-depth studies related to common health problems afflicting our
people.
• Generating scientific data in various medical and allied fields.”

Basically, the dissertation is an original work of research that is carefully preparing over
the course of FCPS training and must be submitted at least 9 months before the date the
trainee wishes to appear in the FCPS-II exam.

THE FCPS-II EXAM

This exam has two components, a paper exam and a clinical/oral exam. The FCPS-II
paper exam consists of 100 MCQ questions while the clinical/oral exam is held with the
cooperation of real patients. When presented with a patient, the candidate will have to
take history, conduct the clinical examination, and propose a management plan. In the
oral component of this part of the exam, the candidate will be thoroughly tested for in-
depth knowledge of his specialty.

The FCPS-II is not considered to be an easy exam. The pass rate is low and it is not
uncommon for doctors to take it more than once before they pass. After passing however,
the FCPS period of training is officially over and the doctor is awarded the highly
regarded FCPS degree, and qualified as a specialist in that field.

THE DCPS PROGRAM

DCPS stands for Diploma of the College of Physicians and Surgeons. The DCPS is a
two year training program structured just like the FCPS program. The minimum criteria for
eligibility is full registration with the PMDC (i.e., the candidate must have finished his
house jobs).

The DCPS program was introduced in 2004 and the first batch of doctors are currently (in
2005) in their first year. There is no entrance exam into the DCPS program (as FCPS-I is
for the FCPS program). However, there is an exit exam which will be conducted in 2006
for the first batch of DCPS doctors - the precise structure and content of which is still
being formulated at the present time.

The DCPS was introduced to correct the deficiency of doctors at the junior TMO level. A
DCPS doctor will be a junior level doctor and will progress only by the strength of his

14
seniority and experience. His promotion and progress therefore will only come about as
the years pass by or if he enters and completes an FCPS program. Currently, it is
proposed that a DCPS doctor who wishes later on to pursue FCPS training will have one
year of his DCPS training counted towards an FCPS. That is to say, a DCPS doctor in
medicine who enters an FCPS program in medicine will only have to train for three years
as a TMO and not the usual four.

The specialties and sub-specialties in which the DCPS program is offered are listed
below. The range of specialties offered reflects the current shortage of junior doctors in
these fields:

• Anesthesia
• Clinical Pathology
• Diagnostic Radiology
• Family Medicine
• Obstetrics (without Gynecology)
• Ophthalmology
• ENT
• Pediatrics
• Dermatology
• Psychiatry
• Community Medicine
• Pulmonology

The DCPS program has replaced the MCPS (Member of College of Physicians and
Surgeons) program. The MCPS was also a training program designed to produce junior
doctors, and was restructured, renamed, and redesigned into DCPS. This change was
effected in order to bring the program on par with similar programs in developed countries
– a move that will lead to its acceptance in developed countries.

PRACTICAL CONSIDERATIONS
Unlike the process of entering UK and US system of post-graduate medical education, in
the Pakistani system there are no visa problems to address, no prolonged, expensive
registration requirements and little (if any) traveling to far off places. Besides these factors
are other practical considerations a doctors must bear in mind when deciding to pursue
the FCPS option.

CLINICAL EXPOSURE
There is little doubt that a TMO working in practically any teaching hospital in Pakistan
would see more patients, and a greater variety of pathologies than doctors training for a
similar period in the US or UK. This is a consequence of the underdeveloped health-care
system in Pakistan (in which the doctor:patient ratio is very low), but it ultimately works to
the advantage of the trainee. In the 4-5 years of his TMOship, the trainee would get much
more practical experience and exposure than his counterparts in developed countries. If

15
the TMO is very hard working and actively incorporates his clinical exposure with formal
in-depth study, he will evolve into a highly competent and experienced doctor. In surgery
for instance, junior TMOs and even house officers quickly learn to perform common major
surgeries, an experience which greatly contributes to their confidence and expertise in a
relatively short time.

QUALITY OF TRAINING
In the US all residency programs must adhere to a minimum standard of training, work
hours and patient load. To ensure that these minimum standards are met, these
programs are kept under tight check by a national Residency Control Commission (RCC).
Vigilant supervision of training programs by the RCC ensures that all teaching hospitals in
the US provide - at the very least – an acceptable standard of active training to its
residents.

In Pakistan, while certain minimum standards are in place (which are mostly concerned
with accrediting hospitals as being fit to offer training) a proactive supervised evaluation
of training standards (similar to that in the US) is not in effect in Pakistan. With a lack of
such standardization arises the inevitable difference in the proficiency and excellence of
the training programs in different hospitals throughout Pakistan. As a result, the quality of
training imparted to FCSP trainees varies greatly from one hospital to the next.

For the most part, the quality of training in any hospital is largely in the hands of its senior
doctors. In some training hospitals, where the senior doctors have the time and
inclination, the TMOs will be regularly monitored and assessed with an active interest
taken in their professional development to ensure their evolvement into competent
doctors. Such environments makes it easier for FCPS trainees to make the most of their
training and evolve into highly competent doctors.

On the other side of the spectrum are training hospitals where the senior doctors are
overworked and simply don’t have the time (or inclination) to focus their energies on their
TMOs. In such places the TMOs suffer the inevitable consequences that come with such
an environment. This is not to say, however, that it will be become impossible for TMOs in
such settings to acquire a high degree of competence in their specialty – rather, they will
have to work harder themselves in order to overcome the short-comings of a training
environment that offers them little instructional support.

Keeping this in mind, choosing a teaching hospital in which to pursue FCPS training
should become an important aspect of planning the FCPS option. Currently, most doctors
choose to pursue FCPS training in the hospitals affiliated with the medical college they
graduated from - with little or no consideration given to the quality of training these
hospitals can offer them. Such an approach is probably strongly influenced by the fact
that the doctor feels comfortable in familiar territory, surrounded by old friends and family
and would continue to work in the environment/city he lived in during his days as a
medical student.

However, with numerous teaching hospitals available throughout Pakistan, a more

calculated approach should be taken when pursuing an FCPS training program. If you
feel you’ll receive a good training experience in a hospital located in a city other than the
16
one you’re currently living in, then that option should be seriously considered and you
should investigate the procedure and requirements needed to get into such a hospital as
an FCPS trainee. Such research is best conducted by talking directly to TMOs working in
that hospital as they would be able to give you the most accurate picture of the quality of
training.

COST OF THE FCPS PATHWAY

By far, entering the FCPS program is the most cost-effective of all the options mentioned
in this manual. The major costs involved are:

FCPS-I Exam Fee: Rs. 9,000

Registration Fee as a FCPS Trainee: Rs. 6,500
Workshops: Rs. 24,500 - 33,000
Dissertation: Rs. 1,000 -15,000*
FCPS-II Exam Fee: Rs. 9,000

*The dissertation costs range from 1,000 to 15,000 depending mostly on whether or not you employ the
services of a computer professional who will type and arrange the format of your document. If you are skilled at
using a word processor and can prepare the document yourself, the cost of preparing the dissertation will be
correspondingly lower.

Assuming that the exams are passed in the first attempt (which is not the case for the
majority of candidates), the costs range from Rs. 49,500 to Rs. 72,000. This is hardly
10% of the costs entailed in the entire USMLE and UK pathways.

It is cheaper to enter the FCPS pathway, but this fact needs to be considered in
conjunction with the “Time and Money” factors described below.

TIME AND MONEY

These two factors are intertwined. Recall that the FCPS program lasts for 4-5 years
(depending on the specialty). Also remember that in our institute, Khyber Medical
College, the final year class has been, in recent years, graduating in December - with the
house job starting in late January. After the house job, there is a one-year delay
(explained above) before the FCPS training begins (provided you pass the FCPS-I exam
in the first attempt). After the 4-5 FCPS years are over, most candidates study for 4-5
months before attempting the FCPS-II exam. If they pass in the first attempt, they will
have successfully completed the pathway. Adding up the years from graduation, the time
taken to complete the FCPS program is approximately 6½ years (for medicine and
surgery) and 7½ years for other specialties like ENT and Ophthalmology.

If you graduate at the age of 24, then you’ll be 30-32 years old by the time you finish the
FCPS. The long amount of time spent training and studying for the FCPS degree is not a
problem in itself. However, the situation does become problematic when the time taken to
complete the FCPS pathway is considered in conjunction with the ‘money factor’.

A TMO is currently paid Rs. 6,200 a month. He will continue to get this stipend for the
duration of his training. It is generally agreed upon that this amount is hardly adequate to
support oneself, let alone one’s parents or family (i.e., wife and children). Resultantly, the
17
FCPS trainee is often in a financially difficult position – a situation that often leads to the
great frustration and anxiety that comes from financial dependence on others. This is a
particularly pressing problem in our poor society where a man in his late 20s or early 30s
is usually expected to be financially independent and be able to contribute to, rather than
drain from, the economic position of his family. (There has been talk of increasing the
stipend from the current Rs. 6,200 a month to Rs. 10,000 a month. However it is unclear
when this development will actually come into effect and if/when it does, to what extent it
would relieve the current financial insecurity of FCPS trainees.)

The financial problem is further compounded by secondary financial demands: The

mandatory workshops cost Rs. 24,500 (for the medical specialties) and Rs. 33,000 (for
the surgical specialties). This is how much money a TMO makes in 4-5 months. Besides
the costs of books, are the costs of preparing the dissertation, which ranges from Rs.
1,000-15,000.

From my examination of post-graduate medical training systems in the UK and US, it is

apparent that the primary motive most people have for seeking further education abroad
is the “time-money” factor. Many doctors in our poor society have financial obligations to
their families they would be unable to discharge with a stipend of Rs. 6,200 a month.
They feel that the relative lack of a rigorously monitored, quality-controlled FCPS training
program, when combined its associated financial drawbacks, add up to make the FCPS
option an unattractive one. This conclusion is manifested by the fact that despite the
exhausting period of study and uncertain visa situation in the US option; and the dire job
situation in the UK option - many doctors still prefer to invest their time and money for a
chance to go abroad for further training.

18
 ---- SECTION B ---- POSTGRADUATE MEDICAL

EDUCATION IN THE UK

THE NHS
The National Health Service, or NHS is responsible for providing healthcare to the
residents of the UK and training the doctors who work for it. The NHS is organized to
maximize the efficiency of health-care delivery. Its structure is somewhat different from
the structure of health care in Pakistan or the US.

THE GPS AND THE SPECIALISTS

If you are living in the UK and you get sick, you will go to what is called the General
Practitioner, or GP. Every citizen in the UK is entitled to be registered with the GP near
his locality. He will be your personal doctor, and whenever you fall ill, you will go to him
first. He may diagnose your illness and treat you, or if he feels that your illness requires
the expertise of a Specialist, he will refer you to one. The advantage of this system is
that when the patient first interacts with his healthcare system, he is managed in a way
that maximizes the efficiency of health-care delivery. If the ailment is simple and within
the ability of the GP to treat, there will no further need to burden the NHS with the case.
Furthermore, after seeing the patient, the GP will, if nothing else, be able to refer the
patient to the Specialist that can best treat him. In countries where this system is lacking,
the fragmentation of medicine and surgery into so many specialties can make it difficult
for the patient to decide which department he should go to seek a cure. The patient for
example, may go to a pulmonologist for his breathlessness while his actual problem is
cardiac. At best, such inappropriate visits can simply cause an added burden on the
healthcare system and at worst, can cause an incorrect diagnosis.

The reason this distinction is important for our purposes is that overseas doctors who
train and work as GPs in the UK may find it difficult to return and practice in their home
countries where the healthcare system is not organized to have a well-defined role for
such doctors. This consideration must be made before any overseas doctor decides
firmly that he wishes to pursue a career as a GP because in the UK, a GP’s skills and
professional development is influenced by a network of Specialists he can call on
whenever he feels the need.

BASIC AND HIGHER SPECIALIST TRAINING

To train to become a specialist, the doctor must pass through two stages of training. The
first stage is called General Professional Training which will probably be known in the
19
future as the Basic Specialist Training. This training is imparted during the time spent
as an Senior House Officer (which is explained below).

The second stage is called Higher Specialist Training – which lasts during the time
spent as a Specialist Registrar (SpR) (which is explained below).

THE DIFFERENT GRADES

Thus the doctors in the NHS can be broadly groups into the GPs and the Specialists.

However, the categorization is not that simple. Doctors in the NHS are in “grades”
reflecting their position in the hierarchy of the NHS. As doctors get into higher grades,
they get paid more, assume greater responsibility and, it must be said, attain greater
prestige as well.

THE PRHO GRADE

The lowest grade is the Pre-Registration House Officer (PRHO). UK graduates enter
this grade immediately after graduating from medical college. The term “pre-registration”
is applied to this grade because after completing it, the doctors are “fully registered” in the
General Medical Council, or GMC of the UK. They are, in other words, registered as
doctors. This is similar to the Pakistani system, where an MBBS student is only registered
with the PMDC as a Registered Medical Practitioner (RMP) after completing a one year
house job. The PRHO lasts for one year after which doctors compete for posts (i.e., jobs)
in the Senior House Officer (SHO) grade.

The overwhelming majority of overseas doctors coming to the UK today compete for the
SHO posts. There are very few PRHO posts for overseas doctors, so not many get them.
This is why most doctors who apply for posts in the UK do so only after they have
completed house jobs in their home countries.

THE SHO GRADE

SHO posts last for 6 months in a certain specialty. Job opportunities for SHO posts are
advertised openly and awarded on a competitive basis. After finishing one SHO posting,
doctors apply for the next, and then the next, and so one until they leave this grade by
attaining their Membership of a Royal College (MRC) - which we will come to shortly.
Doctors remain in this grade until they attain their Membership. However it is possible
(and this in fact has become a big problem for the NHS) that doctors simply stay in the
SHO grade for 8-9 years before getting around to completing their memberships. Indeed,
currently there isn’t a built-in mechanism within the NHS structure compelling doctors to
attain their membership quickly and leave this grade. Ideally, the doctor should attain his
Membership within 3-4 years and move forward, taking on greater responsibilities, and
making room for newer doctors in the SHO grade.

The different SHOships are not centrally integrated by any educational body. This makes
it difficult (at least to the overseas doctor whose does not have the luxury of rejecting any
SHO post he is given) to ensure that the time spent in the SHO grade will follow a well-
20
planned, integrated programme. This is in sharp contrast to the US system where a US
resident has a fixed contract with a certain hospital and will continue to work and train
there for several years. If he has chosen go into Internal Medicine, he will spend a fixed
amount of time in the different subspecialties of Internal Medicine and be transferred from
one ward to the next without any interruption of his training.

The reasoning behind limiting the SHO posts to 6 months at a time, with no centrally
decided integration between the different SHO posts is to give the doctor the opportunity
to sample different specialties. If for example, he wishes to experience Nephrology, he
can take a 6-month job in it. If he wants, his next post can be in Psychiatry. By spending 6
months in such posts, he will be able to decide if he wants to pursue that field as a
specialist, and even if he doesn’t, the exposure and knowledge learned in that field will
add to his body of knowledge and make him a well-rounded doctor.

However this system was designed and set in place decades ago, when competition for
SHO posts was not as fierce as it is now. So, while the theory of 6-month SHOships
seems fine, the system becomes flawed when the SHOship that a doctor enters is not out
of choice, but out of compulsion - caused by today’s difficult job situation. This problem
hits overseas doctors the hardest, who are considered for SHO posts only after UK-
graduates are accommodated first.

Since there is no link between the first and second SHO post, it is quite possible for you
to be exposed to very different specialties during your time as an SHO. One post could be
in Cardiology for example and the next in Psychiatry. For the overseas doctor, its a matter
of taking what you can get.

Having said that however, it must be emphasized that the training imparted during the
SHOship is quite good. A hard working doctor can benefit immensely and learn a lot
during his time as an SHO. Another important clarification to the above is that not all
SHO posts are 6-month contracts. They can be 2-3 year contracts in which planned,
integrated rotations are structured into the training. However it is very difficult for
overseas graduates to obtain such contracts. The vast majority receive 6-month posts.

During the SHOships, the doctor will study and train for the Membership exams of one of
the Royal Colleges. There are a number of Royal Colleges for the different generic
specialties (by generic we mean the large specialties, like medicine – not the
subspecialties within them like Nephrology). The Royal College of Physicians, for
example is responsible for Medicine. We also have the Royal College of Radiology, Royal
College of Psychiatry, Royal College of Ophthalmology, Royal College of Obstetrics and
Gynecology and so on.

A doctor becomes a “member” of a Royal College when he passes that college’s

membership exams. For example, if a doctor wishes to progress as a surgeon, he will
have to pass the Membership exams prepared, administered and assessed by the Royal
College of Surgeons. If he is able to pass the exams, he will be an MRCS (Member of the
Royal College of Surgeons) and eligible to advance to one of the grades above that of an
SHO. These are:

21
 1. Staff Grade
2. Specialist Registrar (SpR) Type I
3. Specialist Registrar (SpR) Type II (FTTA)

THE STAFF GRADE

The staff grade is a post in which the doctor does not have a chance of progressing
career-wise to reach a consultant grade. The reason for this is that the staff grade is a
non-training post. Training elements incorporated into this post are not formally
recognized by the Specialist Training Authority (STA). Since becoming a consultant
requires its own training program (that has to be approved by the STA) a staff grade
doctor cannot improve on his credentials to become a consultant. The inability of the SAS
doctors to progress towards a consultant grade has given this group of doctors a lot to
complain about.

If a doctor works in a staff grade for 10 years, he is entitled to an Associate Specialist

grade – which is a more senior grade with a higher pay scale. The Staff grade and
Associate Specialist doctors are collectively referred to as the SAS Doctors.

Some hospitals have a tradition of actively teaching and training its staff grade doctors on
par with the SpR doctors (SpR posts are explained below) – even if this training is not
officially recognized by the STA. Therefore, an overseas doctor who is interested in going
to the UK primarily to improve his expertise can still do so in a good staff grade job.
However it is equally likely for a staff grade doctors to be neglected if the consultants in
the hospital don’t make it a priority to actively train them. Staff grade doctors therefore
may or may not receive active training depending entirely on the senior doctors who they
are working under. The best thing to do for an overseas doctor is to have a CV strong
enough to obtain a staff grade post in a hospital that has a long standing tradition of
actively training its staff grade doctors.

With regards to the staff grade post, Graham Buckley, the Director of the Scottish Council
for Postgraduate Medical and Dental Education, made the following points:

• The posts are not for training. They are non-consultant career posts.[see “Terms not
already covered” below for definition of non-consultant career posts]
• Traditionally, the British medical profession has been hostile to the development of
non-consultant career grade staff, expressing this through both the BMA and the
royal colleges. Grades such as the staff grade…have been perceived as a threat to
standards.
• It should be clearly understood that the staff grade is not a route to becoming a
consultant.
• …the implementation of shorter and more structured training for specialist registrars,
has left a service gap which has been filled by staff grade doctors.
• The content of the work of staff grade doctors and their working hours is clearly
varied. It is this flexibility in filling awkward gaps in the service that makes these
doctors such a key component in the medical workforce and should lead to their
achieving higher status

22
• At present, the staff grade posts seem to be a lottery, with job satisfaction highly
dependent on the approach taken by the supervising consultants.

TYPE I SPR POSTS

In order for a doctor to attain a Consultant grade (the highest in the NHS) he will have to
go through a formally recognized, well-planned, specialty training program called Higher
Specialist Training (HST) which lasts from 4 to 6 years, depending on the specialty. A
doctor admitted into an HST programme will have the grade of a Type I Specialist
Registrar. After completing the HST programme, he will be awarded the Certificate of
Completion of Specialist Training (CCST), which entitles him to the Consultant grade.

A doctor in an HST programme as a Type I SpR will be given a National Training

Number (NTN), which registers him as a doctor on his way towards a consultancy grade.
The NTN is only awarded to those doctors who have permanent resident rights in the UK
(i.e., they are allowed to live and work there just like British citizens). Overseas doctors
without such resident rights are given a Visiting Training Number (VTN) instead. By
awarding VTN/NTNs to aspiring consultants, the NHS manages to keep track of the
number of consultants that will be available to the NHS a few years down the road when
these doctors complete their HST training. The NHS keeps this careful count of the
number of its consultants-to-be in order to avoid creating more consultants in a specialty
than are needed. For example, if the NHS predicts that it will require 3000 Cardiologists in
the year 2008, it will make sure that the number of VTN/NTNs that it assigns to doctors
entering HST in Cardiology does not cause the target of 3000 Cardiologists to be
exceeded in the year 2008. The reason they pay such careful attention to the number of
consultants in any specialty is because these consultants, being at the top of the NHS
hierarchy must have jobs when they finish. After the huge investment made training them,
the NHS cannot afford to have unemployed consultants.

Consequently, there is fixed number of VTN/NTNs available to be assigned - the number

depending on the needs of NHS at the given time. Competition to get a Type I SpR post
is currently very fierce even for UK graduates. This post is, after all, the key to getting to
the top of the NHS. For overseas graduates Type I SpR posts in some specialties (such
as cardiology, neurology, gastroenterology, respiratory medicine, general surgery and
orthopedics) are exceedingly difficult to obtain.

TYPE II (FTTA) SPR POSTS

The Type II SpR posts are more commonly referred to as the Fixed Term Training
Appointment (FTTA) posts. FTTA posts are also SpR posts. They identical to Type I
SpR posts in terms of content, duties, and training components - however they do not
lead to an CCST, which means that they do not lead to a consultant grade. While the
Type I SpR posts are contracts that last for four to six years, the FTTA posts seldom for
more than 2.

These posts exist for two reasons. Firstly to accommodate overseas doctors who wish to
work in an HST programme in order to gain expertise they would return to their own
countries with – and secondly to fill deficiencies in the number of junior SpR doctors

23
without creating more consultants than are needed. For the second reason UK doctors,
and not just overseas doctors, are eligible to apply for FTTA posts.

In a few years time, the number of FTTA posts will be reduced to almost nothing.
Currently, the NHS is facing a consultant-deficiency crisis. It needs more consultants in
the system and as a result the work-force space previously occupied by the FTTA posts
is being taken over by Type I SpR posts. By doing this, the NHS aims to overcome the
consultant-deficiency crisis it is currently facing in a few years time.

Increasing the number of Type I SpR posts at the expense of FTTA posts probably does
not bode well for overseas doctors who wish to gain further training in an HST
programme. It is widely believed that UK doctors are actively preferred over overseas
doctors when it comes to awarding Type I SpR posts. Therefore overseas doctors who
previously stood a chance at obtaining at least an FTTA post will have this option cut off
for them as well.

To illustrate, the following is an excerpt from the Advice Zone section of a BMJ Careers
issue dated June 19th 2004:

Question: What are the chances of a non-European Union resident getting a type 1
training number in orthopedics? Is there any chance that I could be a consultant in
orthopedics in the United Kingdom? (I am a Pakistani national.)

Answer: Dr Phil Hammond, the comedian and general practitioner, has recently written a
sitcom about an Asian orthopedic surgeon who struggled to get the top London teaching
hospital job that he wanted but instead was banished to the Isle of Wight. Sadly, this
does reflect the prejudice that remains in the 21st century among the medical community.
“Racism blocks the career progression of doctors from ethnic minorities and from
overseas,” a BMA report said (BMJ 2003;326:1418). It saddens me to quote such a line,
but all the evidence is there that it is no doubt more difficult to get the job you want if you
are from overseas.….

Andy Goldberg
Specialist Registrar in Orthopedics
Whittington Hospital NHS Trust

Since the year 2000, which saw a massive increase in the number of overseas doctors
coming to the UK (an increase that still continues), the number of overseas doctors
attaining Type I SpR posts has been declining steadily.

It is worth mentioning here that a few years back, there were Registrar and Senior
Registrar Grades. If you come across these terms you may ignore them. These posts no
longer exist - they have been replaced by the SpR posts.

Those who do not wish to train to become consultants or are unable to get a Type I SpR
post are compelled to enter the staff grade (which as already been explained) or Trust
Grade Post.

24
TRUST POSTS
A “trust” refers to a small number of hospitals which are collectively responsible for the
population in a certain area (like a county, or a city for example). There are a little over
300 trusts in the UK.

The NHS is very exact about giving trusts the precise extent of financial, structural and
workforce resources needed to deliver healthcare to the locality under the trust’s care.
Giving too much money or allotting too many doctors to a trust would be wasteful. The
size of the workforce in each trust is therefore closely monitored by the NHS.

However, each trust is allowed some flexibility. When a trust feels that it there is a need
for a doctor in a certain grade, whatever that grade may be (PRHO, SHO, SpR or Staff
grade) the trust will create a post to fill that particular gap in its workforce. The post
created to fill this gap is the “trust post”. The ability of trusts to create such posts as and
when needed is essential to quickly fill up gaps in the workforce that may prove to be only
temporary. If, as time passes, the trust finds that the gap is permanent, then it will request
the central authority in the NHS to increase the number of doctors allotted to the trust in
the grade which is deficient.

During the period of time when it is not yet clear to the trust whether this gap will become
permanent or not, the trust post remains a non-permanent grade, and its job contract is
not a “standard” one. The trust grade doctor does not enjoy any of the privileges that the
other “standard” grades provide. Furthermore, since the trust does not know if the gap
being filled by the trust post will become permanent, the post offered can be terminated
when and if it is thought that the need for the post is not longer there. As a result, the trust
grade posts, are not secure and more importantly, they are not be recognized for training.

It is clear therefore that trust posts are created for the benefit of the trusts, not the doctors
who work for them in that capacity. This situation has caused much criticism as many
believe that trust posts exploit doctors, especially overseas doctors, who are forced to
these posts simply because they can’t find a standard post elsewhere.

A BMJ Careers article dated 3rd January, 2004 focused on these so called non-standard
grade doctors. A panel of professionals discussed the issue:

Sam Lingam, former chairman of the British International Doctors Association,

told the panel that his association advised doctors to take such posts if that was
all that was available. "Without trust grade doctors they will have nothing. They
will be homeless and jobless." He continued: "We say to them, `take what's
there, for now.' There are many doctors who have the PLAB [Professional and
Linguistic Assessments Board test] and so are job ready but find it difficult to get
jobs. They have great difficulty even getting a clinical attachment. We advise
them to take what is available."

Steve Field [postgraduate dean of the West Midlands Deanery]…disagreed that

doctors should take up such posts out of desperation, calling this "abusive
behavior" and the alternative to working at McDonalds or something like it. He
said, "We are abusing doctors rather than valuing them."
25
The lesson to be learnt here regarding trust grade positions is that they can be used by
overseas doctors if they are desperate for a job, however it should also be kept in mind
that not all trust grade posts are necessarily bad. Some trusts take conscientious
responsibility in developing their trust doctor’s expertise during his time there. However,
when circumstances permit, one should leave the trust grade when they can get a
standard grade post.

LOCUMS
Locums are temporary posts in which a doctor fills in for an absent doctor already
employed by the NHS. If a doctor in the NHS is sick, (or in case of a woman, requires
maternity leave), on study leave, or on vacation, then a locum doctor will be appointed to
perform the duties of the doctor on leave. Locums will last for as long as the other doctor
is absent from duty and can be in any of the grades. As such, they can last from a few
days to a few months, but rarely longer than that. Locums can be in any of the grades,
and they have in the past served as a valuable source of money for otherwise
unemployed doctors living in the UK, seeking jobs. A locum at an SHO grade for a month
can earn the doctor up to 2000 Pounds Sterling, and as such, can greatly relieve his
financial difficulties. The job situation and the monetary considerations of the UK option
are discussed below.

Getting a locum can not only provide much needed financial relief, but also valuable UK
work experience that will add to your CV. There are locum agencies in the UK through
which most junior doctors obtain their locums, but as the locum employer is usually a
senior doctor working in the hospital, knowing such a doctor (or someone who can put in
a good word for you on your behalf) can be instrumental in securing a locum post.

THE MEMBERSHIP EXAMS

The membership exams of the Royal Colleges have multiple parts that are given over a
space of a few years. Every Royal College responsible for its specialty publishes a
Regulation and Information Manual every year that contains details on the different
parts of the Membership exam, their formats, the centers where they can be taken,
application forms, fees, rules of exemption from different parts of the exam - and a lot
more.

To illustrate how the membership exams are structured, we’ll go through the following
flow chart that describes how to obtain a Membership of the Royal College of Physicians
(which is responsible for generic specialty of Medicine).

26
27
Currently the first part of the MRCP(UK) exam can only be given when 18 months have
elapsed from the date of graduation. This prerequisite may or may not change. As we
shall see, the NHS is overseeing extensive reforms in the SHO grade and it is quite
possible that the membership exam details may be affected by these reforms. One must
use only the most current Exam manual from the relevant Royal College to keep abreast
of the changing situation.

The MRCP(UK) Part 1 exam consists of two papers in an MCQ format containing 100
questions each. The composition of the different subjects tested in this exam is as
follows; the number refers to the number of questions in both papers that will come from
that subject.

• Cardiology 15
• Clinical hematology and oncology 15
• Clinical pharmacology, therapeutics and toxicology 20
• Clinical Sciences 25
• Dermatology 8
• Endocrinology 15
• Gastroenterology 15
• Infectious diseases and tropical medicine and sexually transmitted diseases 15
• Nephrology 15
• Neurology 15
• Ophthalmology 4
• Psychiatry 8
• Respiratory medicine 15
• Rheumatology 15

Clinical sciences comprise:

• Cell, molecular and membrane biology 2
• Clinical anatomy 3
• Clinical biochemistry and metabolism 4
• Clinical physiology 4
• Genetics 3
• Immunology 4
• Statistics, epidemiology and evidence-based medicine 5

After passing the Part I exam (the result is mailed 4 weeks after the exam). The candidate
is eligible to sit for the MRCP(UK) Part 2 exam. The Part 2 exam can be given 6 months
after the Part I exam if the candidate feels he is ready.

The MRCP(UK) Part 2 exam also consists of 2 MCQ papers of 100 questions each. The
composition of the exam is as follows:

• Cardiology 20
• Dermatology 8
• Endocrinology and metabolic medicine 20

28
• Gastroenterology 20
• Hematology/ Immunology 10
• Infectious diseases and GUM 18
• Neurology/ Ophthalmology/ Psychiatry 22
• Oncology and palliative medicine 10
• Renal medicine 20
• Respiratory medicine 20
• Rheumatology 12
• Therapeutics and toxicology 20

If the candidate fails the Part 2 exam, he is free to try again. The only restriction to the
number of attempts he can make is that he must pass this exam within 7 years of passing
the Part I exam.

The pass result of the Part 2 exam is valid for only two and a half years. The candidate
must sit for the 3rd and last part of the membership exam before these two and a half
years expire. He is eligible to sit for the third part of the exam 6 months after passing his
Part 2. Therefore, the window of time available to him to pass the third part of the exam is
2 years. This 2 year period is called the Period of Eligibility and begins 6 months after the
part 2 is passed. To illustrate: if a candidate passed his Part 2 in April 2005, then his
period of eligibility for the third part will start from October 2005 and last till October
2007. If he has not taken the last part within the Period of Eligibility, he will be compelled
to retake the Part 2 exam.

The last part of the membership exam is called PACES, the Practical Assessment of
Clinical Examination Skills. To quote from the 2004 Regulations and Information to
Candidates Manual:

“The MRCP(UK) Part 2 Clinical Examination (PACES) is composed of five stations (three
‘clinical’ and two ‘talking’), each assessed by two independent examiners. Candidates will
start at any one of the five stations and then move round the carousel of stations at 20-
minute intervals until the cycle has been completed. The stations are:

Station 1
Respiratory System Examination (10 minutes)
Abdominal System Examination(10 minutes)

Station 2
History Taking Skills (20 minutes)

Station 3
Cardiovascular System Examination (10 minutes)
Central Nervous System Examination (10 minutes)

Station 4
Communication Skills and Ethics (20 minutes)

Station 5
29
Skin / Locomotor / Endocrine / Eye Examination (20 minutes)

The MRCP(UK) Part 2 Clinical Examination (PACES) lasts a total of 120 minutes
(including four 5-minute breaks between stations).”

If the candidate passes, he will be awarded the MRCP(UK) diploma.

It should be mentioned here that the MRC diploma, particularly the MRCP(UK) diploma
has become internationalized. Training in the UK is not an essential prerequisite to taking
any of the 3 parts of the exam. There are MRC exam centers established in 14 countries
around the world (Saudi Arabia, Oman, Singapore, Kuwait, and Sri Lanka, to name a
few). Pakistan has no such centers, and if Pakistani doctors are training and studying for
the MRCP in Pakistan, they must travel to the UK to give them (they cannot go to a non-
UK center – those centers are established only for those doctors training there).

There are thousands of MRCs across the world who only go to the UK to take the exam
and after passing, return to work in their home countries or seek jobs elsewhere.
Obtaining the MRCP(UK) demonstrates a competitive level of competence and can help
to further the careers of overseas doctors in their own home countries as well as creating
opportunities for them to find jobs in other countries. Many MRCP(UK) doctors, for
example, use this qualification to seek jobs in the Gulf states, where this degree is highly
valued.

TERMS NOT ALREADY COVERED

Basic Specialist Training OR General Professional Training
This refers to the training received at the SHO grade.

Career Grades
The non-training grades - namely the Consultants, Staff grades, Associate Specialist
Grades, and the trust grade posts.

Non-Consultant Career Grades

Synonymous with the Staff and Associate Specialist grades. Doctors in the SAS/NCC
grades cannot progress further up the NHS hierarchy because they are non-training
posts. The emphasis on this grade being a “non-consultant” one is made because while a
consultant grade is a career grade, it is at the top of the NHS hierarchy and as such,
highly regarded. All other career grades (i.e., the “non-consultant ones) are seen to be
(often frustratingly) dead ends to further NHS progression.

MRCP; MRCS
An MRCP(UK) doctor is a Member of the Royal College of Physicians of the United
Kingdom. The MRCP(UK) refers not only to the member, but is also used to refer to the
exams needed to pass to become a member, e.g., MRCP Part I exam and so on. The
MRCP exam deals with the specialty of medicine. A doctor must be an MRCP(UK), in
other words, he must have gotten ‘his membership’ before being able to proceed to
Higher Specialist Training in a medical subspecialty.
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There are other “memberships” like the MRCS, which stands for the Member of the Royal
College or Surgeons. Each specialty in the UK has its own membership exam and
passing them will give you the “membership” into that Royal College.

FRCP
When a member of a Royal College of Physicians stands out in his career as having high
academic output, as being ethical (and a number of other criteria), he can be considered
for elevation to a Fellow. No exam is taken to become a Fellow – a doctor is considered
for a fellowship by the Royal College of Physicians only after receiving written
recommendations by two other doctors (who must be Fellows themselves). The Royal
College will consider the applications of the two Fellows who recommended the doctor
and if the Royal College approves their recommendation, they will grant the MRCP doctor
a fellowship after which he will be entitled to refer to himself as an FRCP. It is simply an
honorary title, and does not change anything besides cementing the doctor’s reputation.
This “Fellowship” should not be confused with the Fellowship of the US system, which is
earned after passing through a certain, specific programme.

FRCS
The process of becoming a Fellow of the Royal College of Surgeons is exam based,
unlike the FRCP. It is taken near the end of a surgeon’s Higher Specialist Training, with
the exam being different for the different sub-specialties – for example an FRCS(UR) is a
surgeon in Urology and an FRCS(NS) is a neurosurgeon, etc…

Honorary or supernumerary post

An honorary post is an unsalaried post. The doctor may receive funding from a grant,
fellowship or bursary. A supernumerary post is a post that has been created by
placements additional to the agreed number of trainees in approved training posts. A post
may be both supernumerary and honorary.

Rotation
This refers to the move from one post or specialty to another. In a period of employment a
doctor may have one or more rotation.

Substantive Post
A substantive post is an established permanent post.

Locum Appointments for Training

A Locum Appointment for Training (LAT) is created when there is a vacancy in a
recognized training post. The entry criteria for a LAT are the same as for an SpR
appointment; the trainee would be appointed at interview in open competition. Each LAT
will be three months or more, up to one year, of training in an appropriately approved
post. LATs may be accredited towards a CCST programme by the Regional Adviser
when the trainee has obtained an VTN/NTN.

Locum Appointments for Service

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A Locum Appointment for Service (LAS) does not receive any credit for training and
should normally be limited to three months.

Programme
A formal alignment or rotation of posts together comprising a programme of training in a
given specialty(ies) which counts towards the award of a CCST.

Specialist Register
A formal listing of all doctors who are in Type I SpR training. From 1 January 1997
inclusion in the Specialist Register became a legal requirement for taking up a
substantive Consultant post in the NHS. (Do not confuse with Specialist Registrar.)

MODERNIZING MEDICAL CAREERS – HOW THE SYSTEM

IS CHANGING AND HOW OVERSEAS DOCTOR WILL BE
AFFECTED
MODERNIZING MEDICAL CAREERS (MMC)
In August 2002, The Chief Medical Officer of the UK published a paper called "Unfinished
Business, Proposals for Reform of the Senior House Officer grade”. It had been
recognized for years that the General Professional Training administered through the
SHO system had many drawbacks. This paper proposed changes to the SHO grade in
order to remove those flaws. Subsequently, a body was set up, called Modernizing
Medical Careers (MMC) to implement these changes.

The reforms that are being introduced to replace this system are far from universally
approved. Many doctors in the UK feel that the reforms suggested by Unfinished
Business have as many drawbacks as the system currently in place. Be that as it may,
the reforms are due to start on a national level in August of 2005 and only time will tell
how effective they will be in improving the current system and (more importantly for us)
how overseas doctors will be affected by them.

INTEGRATING THE “OLD” SYSTEM WITH THE “NEW” SYSTEM

The previous section “Postgraduate Medical Education in the UK” described the structure
of the system in place at the time of writing (January, 2005). This current system will
begin to undergo massive restructuring starting from August 2005 to be completely in
place by August 2007.

Before getting into the details of the proposed new system, here is a summery of how the
present system works - currently, when a doctor ends his PRHO post, he actively
competes for SHO posts in a variety of specialties which lasts for 6 months each. He
does this for a period of years during which he completes his Membership in one of the
Royal Colleges. After doing so, he competes actively for Type I SpR posts in a certain
subspecialty, or failing that, enters into a staff or trust grade post.

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In order to understand the proposed new system, you need to understand the old one first
so you can correlate the two. To this end, in the text that follows, I have emphasized the
correlation between the current system and the proposed new system in order to provide
a point of reference from which the new system can be better understood. In the text that
follows, my statements of correlation will begin with the words “Compared to the old
system…”

For convenience’s sake, the present system (that is, the one still in place as of January,
2005 – the time of this writing) will be referred to from now on as the “old” system and the
system set to be introduced in August, 2005 will be referred to as the “new” system.

THE FOUNDATION PROGRAMME

In the new system, after British medical students graduate, they will enter a 2-year
Foundation Programme.

The first year of this programme is called Foundation Year 1 or FY1. Starting August
2005, all British medical graduates will automatically enter an FY1 post. FY1 consists of 3
rotations each lasting 4 months - one in medicine, the second in surgery and the third in
another specialty.

The PRHO post of the old system will no longer exist as the FY1 will move in to take its
place. However, compared to the old system, in content and availability of posts, FY1
closely resembles the PRHO post - and as such will represent the same level of difficulty
for overseas doctors to attain.

After completing 12 months in FY1 the doctors will move on immediately to Foundation
Year 2 or FY2. This will happen in August, 2006 – the date when FY2 will be introduced
nationally.

The FY2 is a completely new grade, which did not exist previously. Compared to the old
system there is no counterpart for FY2. The FY2 will consist of 3 rotations (in 3 different
specialties) lasting 4 months each. Besides specialty-specific exposure and training, FY2
doctor will be also be trained in the following “generic” skills:

• Clinical Skills
• Effective relationships with patients
• High standards in clinical governance and patient safety
• Use of evidence and data
• Communication, team working, multi-professional practice etc.
• Understanding of the different settings in which medicine is practiced
• Care of acutely ill patients

The FY2 was created in order to train doctors in essential generic skills which will be of
use to them regardless of the specialty they end up pursuing. Besides this, exposing
doctors early on to different specialties will, theoretically, give them a chance to sample
different specialties so they stand a chance of making a more informed decision of the
specialty they wish to pursue later on. Compared to the old system there was no such
33
post that actively concentrated on these generic skills. In effect, the FY2 post is seen as a
major innovation to the UK post-graduate medical system.

During their time spent in FY2, the doctors will be actively assessed by their supervising
consultants. In such assessments, the FY2 doctors will have to practically demonstrate
that they are competent in the generic skills listed above. If they succeed in doing so, the
fact will be formally documented.

In other words, during the course of the programme, the doctor does not need to give any
membership exams to prove his competency. His documented assessments will be the
qualification needed to move forward after he finishes the programme. This form of
assessment is called “competency based” – i.e., a positive assessment will be written
for him only when he practically demonstrates his competency to his supervisors - not by
passing some exam. Competency-based assessments is a recurring theme in the MMC
reforms, and may have significant consequences for overseas doctors, as we shall soon
see.

Ultimately, the first batch of “foundationers” will finish the programme in August 2007 and
move on to the next stage.

AFTER THE FOUNDATION PROGRAMME

According to a November 2004 Careers BMJ issue,

Three years is hardly any time to implement a new framework for doctors’
training, and yet 2007 is the date set to roll out the full complement of training
reforms for specialist training to be in place. The Modernizing Medical Careers
working party responsible for overseeing the changes, openly agrees that there is
still a lot to do. According to Derek Gallen, a member of the working party, most
of the plans for what happens after exiting foundation programmes are “still up in
the air.”

Whatever structure it takes, the next step after the Foundation programme will be to enter
an coherent and well-structured specialist training programme. In other words, once you
enter the programme that follows the Foundation posts, you should not have to compete
for jobs every 6 months, but continue to remain in the same training programme for least
a number of years. By contrast, compared to the old system, doctors would have to
compete regularly for SHO posts.

Entry into the programmes following the Foundation programme would be made on a
competitive basis. The criteria for selecting a candidate will be his competency based
assessments, which were made during his time in the Foundation programme. There is
no parallel to this compared to the old system. That being the case, an overseas doctor
may find it difficult to secure his place in a post-foundation programme without having
gone through the foundation programme himself.

As the issue of what will happen after the Foundation programme has to be faced in
August 2007, the structure of the post-foundation programme has not yet been formally
agreed upon at the time of writing (i.e., it is “still up in the air”). However, currently the
34
consensus is that a post-foundation programme will follow one of the following two
formats:

THE FIRST PROPOSAL

The first proposal is that FY2 should be followed up a 2-3 year Basic Specialist
Training, BST (Keep in mind that if the BST proposal is adopted, it will start from 2007.
Therefore, currently the term ‘Basic Specialist Training’ is not in widespread use. I am
pointing this out to avoid possible confusion with another BST acronym which stands for
Basic Surgical Training. This is a simply 3-day course offered to junior doctors in surgical
specialties. It should not be confused for the Basic Specialist Training).

Compared to the old system, the BST is equivalent to the General Professional Training
(GPT) a doctor attains during his different SHO posts. Therefore, a doctor in a BST
program in the new system would be equivalent to an SHO in the old system.

The BST will be offered in one of the following 8 specialties:

• General Medicine,
• General Surgery,
• Child Health,
• General Practice,
• Obstetrics & Gynecology,
• Mental Health,
• Anesthetics,
• General Pathology

If a doctor decides to enter a BST programme in General Medicine, he would be rotated

through different specialties for those 3 years and will have to complete his MRCP(UK)
qualification during that time. Compared to the old system such well-planned rotations
through the different specialties of medicine (or any other specialty) was very difficult for
overseas doctors who were compelled, by the difficult job situation, to take whatever SHO
rotations they could get.

The BST programme will be a continuous, uninterrupted contract lasting 2-3 years
(depending on the specialty). After the doctor gets the contract, he will not have to
compete for a job until his BST is over. During the BST, he will study for and complete his
membership in the Royal College of his specialty. (This is actually very similar to the
Residency programmes of in the US system.)

Compared to the old system, the attainment a membership in a Royal College was up to
the SHO. He could stay in SHO posts for years and not gain membership. In the new
system however, he would have to finish his membership during his BST training period.
Once his BST is over, the doctor will compete for a place in a Higher Specialist Training
(HST) programme for training in a subspecialty. If for example, after finishing a BST in
General Medicine, a doctor wishes to enter a HST programme in Neurology, he would

35
have to compete for such programmes using his ‘competency-based’ assessment profiles
of the preceding years of his career as well as other qualifications he has picked up (by
“Growing his CV” - which is explained below). Once he enters the HST programme, he
will be given an NTN/VTN and continue for a number of years, without having to compete
for jobs, until his HST is over. During the course of this HST programme, he will earn his
CCST, Certificate of Completion of Specialist Training and qualify as a consultant.

Compared to the old system, the HST programmes are not a major innovation.
Remember, the MMC reforms are aimed at improving the training of junior doctors in the
SHO grade. Doctors in HST programmes are not junior, and so this part of the system
has not been changed. Even in the old system, the HST programmes were multiple-year
contracts in which the doctors were allocated VTN/NTN numbers. Therefore, this part of
the old system and new system are the same. The grade of a doctor in an HST
programme will be SpR, just as it was in the old system.

The following diagram illustrates the new system.

THE SECOND PROPOSAL

The second proposal is to unify the BST and HST programmes into one seamless
programme that lasts 4-8 years (depending on the specialty). This scheme has been
nicknamed the “run-through” grade – in that the doctor will come straight out of the
Foundation programme and “run-through” a single, unified 4-8 year programme towards a
consultant-ship.

The first few years of this “run-through” programme would involve training in the generic
specialty, and not the subspecialty. For example, if a doctor entered a “run-through”
programme for Gastroenterology, he would not be exclusively trained in just
Gastroenterology for the whole 8 years, but be exposed in the first few years to all the
other Medical sub-specialties as well.

36
Compared to the old system, for the first few years of the “run-through” grade, the doctor
would be equivalent to an SHO of the old system while the latter years, he would be
equivalent to a Type 1 SpR.

USING BOTH PROPOSALS

It is quite possible that the different Royal Colleges will adopt different proposals.
Currently, it is thought that the Royal College of Physicians prefers the first proposal while
the Royal College of Surgeons is leaning towards the second. However, in either case,
the doctors will be inducted to the programmes following the FY2 on the basis of their
competency-based assessment profiles during their time as “foundationers”. This is a
significant point for overseas doctors as we shall see below:

The only difference between the two proposals is that while in the first, the BST and HST
are separated, in the second, they are unified. Therefore, for the sake of simplicity, in the
text that follows, I will refer to the grade following the Foundation programme as the BST
grade.

HOW WILL THE FOUNDATION PROGRAMME AFFECT OVERSEAS

DOCTORS?
The short answer is: no one really knows for sure. Some people say it will improve
matters, while others say it will make things worse. What is clear however is that most
overseas doctors will enter the programme in FY2, not in FY1 (which will be as scarce as
the PRHO posts of the old system).

We will only really find out what consequences the Foundation programme will have for
overseas doctors after August 2006 when the FY2 is formally introduced. However, in my
opinion, things will stand to get a lot harder for overseas doctors in 2006. This is why I
believe this to be the case:

One of the fundamental principles behind the “Unfinished Business” reforms is to

guarantee continuity of training. In other words, the training of junior doctors should
progress seamlessly from one programme to the next, with the next programme building
on the progress made in the first. Therefore, the training programme(s) after FY2 will be
designed in such a way as to build upon the training imparted during FY2.

Resultantly, the consultants hiring junior doctors into programmes that follow FY2 will
assume that the doctor applying has all the generic skills demanded for the successful
completion of the FY2. The only way to prove that a doctor has these skills is to have
favorable “competency-based” assessments – and these can only be attained by going
through the FY2.

Therefore, it follows that when the FY2 is over and doctors start competing for the post-
foundation programmes, the consultants hiring people into these programmes will
actively prefer doctors who have spent a year in FY2. These FY2 doctors will have

37
competency-based assessment profiles that prove they have the generic skills needed to
enter the post-foundation programmes.

Overseas doctors may very well have the same generic skills, but coming from a different
medical education system, they may never have been able to formally document them.

Consider again the generic competencies that an FY2 doctor is supposed to have
attained:
• Clinical Skills
• Effective relationships with patients
• High standards in clinical governance and patient safety
• Use of evidence and data
• Communication, team working, multi-professional practice etc.
• Understanding of the different settings in which medicine is practiced
• Care of acutely ill patients

An overseas doctor may know precisely how to establish an effective relationship with
patients, or how to work in a team, or understand the different settings in which medicine
is practice – but how will he prove it? While the FY2 doctor will have been actively
assessed by his seniors, the overseas doctor will not have had the advantage of such
documented assessments.

This leads us to the possible creation of an immense problem: If FY2 doctors are going to
be actively preferred for post-foundation programmes, then every overseas doctor coming
to the UK in the next few years will concentrate on applying for this one grade, the FY2
because obtaining this post will maximize his chances of getting into a post-foundation
programme. Currently, overseas doctors can apply for SHO posts. SHO posts don’t have
a clearly defined, hierarchical place between the PRHO and the Staff-grade/Consultant
grade post. The SHO posts are currently a set of jobs that fill the blank needed to get the
Membership training experience. With the advent of the FY programme, this vague gap
will be removed. From 2007 onwards, junior doctors will either be in a Foundation
program or in a post-foundation programme. Since the surest way of obtaining a post-
foundation programme is to come from a Foundation programme, and since the only
entry level for overseas doctors will be an FY2, overseas doctors will descend, in their
thousands, on the limited number of FY2 posts in the year 2006.

Keep in mind that this is speculation (and my own personal theory at that) and may prove
not to be the case. For example, one could argue that the NHS is actually introducing a
new grade: the FY2. And because of the introduction of a new grade the job situation may
not change appreciably.

The fact that I’m speculating at all, and not citing references and sources that give precise
predictions of what will happen should in itself communicate the fact that great uncertainty
prevails with regards to this issue amongst the overseas doctors community in the UK.

Another likely effect of introducing the Foundation system is a reduction in the “job
season” from twice a year to once a year. Currently, in the SHO system, the jobs are
available in February and August. However, with the Foundation system, since the FY2
38
(by definition) is a one year contract, they will only be advertised once a year (before
August)

It is also unclear how easy or otherwise it will be for overseas doctors to enter the BST
programmes even if they have done the FY2. Will the traditional bias against overseas
doctors hoping for a training post that leads to an CCST prevail and carry over when they
apply for BST programmes? Will overseas doctors be given 1-year (or less) stand-alone
contracts in the BST programmes? And how difficult will it be for overseas doctors without
an FY2 qualification to enter directly into BST?

These are questions to which those in the Modernizing Medical Careers themselves don’t
have confirmed, guaranteed answers. We will all find out when the times comes, that is
2007 when the BST programmes are scheduled to start.

This sub-section should convey to you the uncertain job situation for overseas doctors of
the next couple of years and encourage you to keep abreast of the situation in order to
maximize your readiness when the time for the move to the UK arrives. No doubt, the
situation will become clearer somewhere in 2006 as the Foundation ‘graduates’ enter the
next stage.

THE SITUATION ON THE GROUND: SOME PRACTICAL

CONSIDERATIONS
THE JOB SITUATION
Most medical students and fresh graduates will already know that the job situation in the
UK is very dismal. A visit to different online forums for overseas doctors looking for jobs in
the UK gives an extremely discouraging picture. In September 2004 the BBC aired a
Newsnight feature on the plight of overseas junior doctors. Some of the comments made
by the doctors interviewed are quoted here:

“I've not been able to get one single job. You feel so low about yourself. You feel
what on earth am I good for.”

“Filling time, unemployed orthopedic doctor, Satish Bhat spends most of his days
filling in forms. 250 job applications in the past six months. He's left his wife and
child in Kerala south India, in search of jobs and training with the NHS.”

“The perception in India is that there is a dire shortage of doctors in the UK. I was
expecting to get a job at least a few months so far, there's no sign. I keep
meeting so many people day in and day out who are in the same boat as I am.
They are also here for months on end without any jobs. Without any hopes of a
job. Moving from place to place, and totally devastated, totally disillusioned.”

“It has been an ordeal here. I'm sure there are several doctors out there who are
going through the same nightmare. Who came here with high hopes, and who

39
 have ended up being emotional wrecks, who've become so frustrated and
disillusioned with the system. I'm sure there are so many of them there.”

Keep in mind that when we talk about the job situation in the UK, it refers mainly to the
SHO-grade (in the new system, it will be the FY2 and BST grades). Competition for the
higher grades is also very tough, but by the time an overseas doctor reaches a level of
qualification that allows him to compete for higher grades, he is already somewhat secure
financially. Resultantly, a difficult job situation for a more senior doctor would not hurt as
much. The hue and cry about the job situation is coming from junior overseas doctors
who come to the UK a year or two after acquiring their medical degree. At present, it is
generally accepted that a doctor going to the UK looking for a junior post will have to
endure at least 6 months of unemployment before landing his first job. However, there is
no telling how much time it will take for the doctor to find a job. The 6 month figure is just
an average generally agreed upon by doctors going there these days. It could be more
than that - or less.

Some people contend that the job situation is not really as bad as is publicized and that
most doctors who do eventually find a job don’t make it a point to come back to the same
forums where they would previously complain about their joblessness. It is argued that
persistence pays off eventually, and land the determined doctor a job.

While this may be true, certain points must be kept in mind. Firstly, finding a job might
relieve the financial stress that comes with unemployed living, but unless the job is a
standard SHO/FY/BST post, there is no guarantee that the job will impart good training.
Trust grades for example, are also considered jobs, but there are many trust grade jobs
with very poor training elements incorporated into them and in any case, even if there
were a training element, it would not be recognized. This is a significant drawback
considering the fact that most doctors go to the UK to seek further training. Secondly, the
interruption of a young doctor’s training by 6 months to 1 year so early in his career is
bound to have some detrimental effect to his competency as a doctor. The blunting of
clinical skills over the time he is away from his profession is a problem he will need to
work hard to overcome once he finds a job.

The simple fact is that there is a case of supply outstripping demand. There are simply
not enough jobs for all the doctors who want one. The best approach an aspiring
overseas doctor can take when entering the arena is to be mentally prepared for the
hardships that lie ahead. If one comes to the UK thinking that things will go smoothly,
then the disappointment he’ll face when things don’t work out that way will be
devastating. As long as an overseas doctor anticipates that there will be hardships and
troubles to contend with, he’ll stand a much better chance at enduring them when they do
come along.

This was not the situation some 5-6 years back. Doctors who went to the UK as early
back as the late 90s didn’t have to face such a difficult job situation. Most got their first
jobs in a few weeks, if that long. However around the turn of the century, the NHS
realized that they were facing a shortage of doctors in the consultant-grade level, and to
remedy this shortage they actively advertised job opportunities in foreign countries (like
India) asking experienced doctors to seek employment in the UK. This initiative by the
40
NHS created the impression that the UK had become a land of opportunity for each and
every type of doctor, regardless of his experience and qualifications. Word spread in the
medical communities of India and Pakistan (the two largest contributors of overseas
doctors in the NHS) that the UK was the place to go. It was assumed erroneously that the
NHS would have ample room for junior doctors as it would for the more senior,
consultant-level doctors. Thus around the turn of the century, the exodus began, and it
has been increasing exponentially, causing the alarming level of unemployment that we
see today.

PROGRESSION OF OVERSEAS DOCTORS IN THE NHS

Currently, an overseas doctor would spend the 3-4 years required to train for his
membership examinations in the SHO grade. When he attains his membership, he is
faced with the following options:

• Return home (or go to another country) to practice there.

• Try to attain a Type I SpR or FTTA post.
• Work in Trust grade or Staff grade posts.

According to the London Deanery, 10% of overseas doctors leave the UK after they have
completed their membership qualification. Of those who choose to remain, 97% of them
go into Staff grade or Trust grade posts. Only 3% of them are able to get into Higher
Specialist Training in an SpR or FTTA capacity soon after their membership is complete.

Currently, 86% of all Type I SpR posts are reserved for UK-graduate doctors. Overseas
doctors may not compete for them. They have to contend amongst themselves for the
remaining 14% of SpR posts.

To quote a BMJCareers article dated 17th August, 2002: “As anyone chasing a much
sought after national training number (NTN) will know only too well, obtaining a type 1
specialist registrar (SpR) training post is arguably the most difficult and stressful hurdle in
clinical training in British hospitals.” This is the situation for UK-graduated doctors back in
2002. The competition amongst overseas doctors is even tougher, and promises to get
even more so.

Perhaps this is the reason why most overseas doctors continue to remain in the trust and
staff grade posts until they return to their own countries, or retire in the UK. In the NHS,
70% of Staff grade and 62% of Associate Specialists are overseas doctors and most of
them will continue to remain in those grades as long as they remain with the NHS. This
has been a source of resentment amongst the overseas doctors community who claim
that they are being preventing from progressing within the NHS to higher grades because
of a bias against them.

For overseas doctors entering the NHS these days, it is clear that the road to a consultant
grade is a hard one. Nothing is impossible of course, for the highly accomplished and
driven doctor. However for those who are unable to attain a very high level of
competitiveness, a realistic goal after membership is a staff grade post with a good
teaching and training environment, ensuring that the doctor continues to learn and

41
develop professionally, even if the increase in his expertise over time is not recognized
officially. In such a setting, he would evolve to become a competent and professional
doctor and that is a goal many would be satisfied with in itself - be it recognized by a
degree/diploma/certificate or not.

THE MONEY FACTOR

An overseas doctor coming to the UK must have strong financial support. He will face the
possibility of anywhere from two to twelve months of unemployment and during this time
he will have to bear his living expenses. He is not allowed to work there (in a non-medical
capacity) so his only source of money will be his own savings (if any) or that of his
guardians. Therefore the average monthly living expenses for people in such a position in
the UK becomes an important issue: How much money will the doctor spend as he looks
for a job? There is no one answer to this as the amount of money a person spends for his
upkeep is affected by several factors: e.g., where he is living in the UK (cities are more
expensive than towns); whether he is sharing the rent with someone else; his own
spending habits; whether he has brought a spouse or family with him, and of course the
length of time before he lands the first job.

On average, one can live decently on 400-700 Pounds/month (with rent) in the UK. This
cost can be more than halved if one is living rent-free with family or friends. It is up to the
individual doctor to look at his financial resources and decide if he can make the
investment required to find a job in the UK.

If a doctor was unemployed for 6 months before getting the first job, he would have spent
4,200 Pounds before getting the first job (using 700 Pounds/month as an average). An
SHO gets paid about 2,000 Pounds/month. The contract lasts for 6 months which means
an earning of 12,000 Pounds during the first job. If he decides to spend his money a little
more freely upon getting the job and increases it up to 900 Pounds/month he would still
be able to save 1,100 pounds every month during his first job. This means that after
completing his first job, he would have 6600 pounds in the bank, easily enough to sustain
him for another 6-7 months as he looks for the next job. It is worth noting that the second
job is much easier to obtain than first one (because the doctor now has experience in the
NHS), and it is unlikely that his savings from the first job would be exhausted before he
found the second one.

This will change of course with the introduction of the FY2/BST grades. The FY2 post is
of one year’s duration and during this time, the doctor can establish a very sound financial
base for himself. However it has to be kept in mind that obtaining the FY2 post may prove
to be more difficult than obtaining an SHO post is now. Furthermore, it is not clear yet
whether overseas doctors will be offered the full 2-3 year contracts in the BST grades as
opposed to 6-month or 1-year stand-alone contracts. Only time will tell how overseas
doctors will be treated in the BST grade.

In any case, from a financial point of view, it is the first job which is the most difficult
hurdle. At that stage, the doctor has no NHS experience to put on his CV, no letters of
recommendation obtained from senior doctors he has worked for in the UK, and no
money. All this changes when he gets the first job. If he gets an FY2 post, it will further
42
strengthen his position as he’ll have competency-based assessments to take him
forward. If he works really hard during the first job to earn himself good letters of
recommendation, spends carefully to save his money, and makes good contacts within
the NHS, then the wait for the second job will be shorter and much easier to endure than
the first.

POSSIBLE ENTRY POINTS INTO THE NHS

It is possible to enter the NHS from your own country at different levels of your
professional development. Currently the vast majority enter at the SHO grade. In 2006
there will be immense competition for the FY2 grade and in 2007 for the BST grades.
Besides the SHO/FY2/BST grades, the other entry points are:

PRHO/FY1
As previously stated, while it is technically possible for an overseas student to obtain his
medical degree and come straight to the UK to do his PRHO or “house job” as it is also
known, it is very difficult to obtain one. All overseas graduates are strongly advised by the
GMC, the BMA, Careers BMJ, and others in the know to do their house jobs in their own
countries and not count on getting one in the UK. To be eligible to apply for a PRHO/FY1
post, the doctor is expect to have attained his medical degree, passed the PLAB and
have a minimum band score of 7 in the IELTS (this is explained below).

STAFF/TRUST GRADE
To be eligible at all for such posts, the candidate must have secured his Membership with
the Royal College (MRC) of his specialty or obtained a degree from his own country of a
comparable level (like the FCPS degree of Pakistan). It is not easy to get these posts
without any UK work experience whatsoever, and it will help the doctor’s chances of
getting such a post if he manages to get a clinical attachment in the UK for a period of
time. It is easier to get locum jobs in the Staff/Trust grades than it is to get longer
contracts, and an overseas doctor entering at this level would be helping his chances if
he concentrated on trying to get locums in this grade first before seeking more long-term
contracts.

As previously mentioned, there are staff grade posts in hospitals reputed for having a
good learning and training environment. An overseas doctor might opt to enter the NHS
at the staff/trust grade post (after completing his MRC or equivalent in his home country)
rather than at the SHO/FY2/BST grade in order to avoid the bad job situation of that
grade. Such doctors, with MRCs or equivalent may be motivated to work in the UK for a
period of years to gain exposure to medical practice in a first world country along with
earning a substantial amount of money during their time there. This is an attractive option
for those doctors who can wait 4-5 years (after obtaining their medical degree) before
going to the UK. In those 4-5 years, they can obtain their memberships and “grow their
CVs” (this is explained below) so their chances of obtaining a good staff grade post is
increased. Ultimately, they’ll have the chance to enter the NHS into a well-paid post with
a good training element allowing them to improve on their expertise.

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CONSULTANT GRADE
A senior, well-qualified, experienced overseas doctor can enter the NHS in a locum
capacity or a more permanent one. The duration of the contract varies on a case-to-case
basis. This is possible at the present time mostly because the NHS is short of consultants
and is actively recruiting them from overseas. However, entering at the consultant grade
is beyond the scope of this manual (which is aimed at junior doctors).

ENTERING AT THE SHO/FY2/BST GRADE

Note: This sub-section provides information on what a doctor must do in order to
enter the SHO/FY2/BST grades. Practically speaking, the FY2 and BST grades
will replace the SHO grade in the next few years. For the sake of convenience
the text that follows uses the term SHO, but it should be understood that all the
information below applies equally to the FY2 and BST grades.

The chronological sequence of qualifications an overseas doctor must attain to be eligible

to apply for an SHO grade are:
1. House job
2. IELTS (can be given even in house job)
3. PLAB 1
4. PLAB 2
5. Registration
6. Finding a job

These individual steps are detailed below:

HOUSE JOB
Since getting a PRHO/FY1 post in the UK is very difficult, the overwhelming majority of
overseas doctors who go to the UK complete their house job in their home countries.

IELTS
The IELTS is a test of the candidate’s English skills. It stands for International English
Language Testing System. People are required to take this exam to prove they have
the minimum acceptable level of proficiency in the English language needed to engage in
their academic or work pursuits in the UK, so its not just for doctors. This exam can be
taken in many countries, including Pakistan. Currently, it costs around 80 Pounds Sterling
and is held twice a month every month throughout the year.

The exam has four sections: Speaking, Listening, Writing and Reading. The result of the
test is given as a number on a scale (called band) from 1 to 9. Each band, or scale
represents a certain level of competency in English. A score of 1 means that the
candidate has only a rudimentary grasp of the language. A score of 9 means the
candidate is as proficient as a native English speaker.
44
Each of the four sections are scored separately on the band of 1 to 9. The individual band
scores in the different sections are then added up to give an average. For example, if a
candidate gets 8 in Speaking, 8 in Listening, 7 in Writing and 7 in Reading it will give him
an overall band score of 7.5.

In order to be eligible to take the PLAB exam, the candidate must have an overall score
of at least 7. However, an imposition is made on the individual scores as well. The
candidate must have at least 7 in the Speaking section and at least 6 in the other
sections. So if a candidate gets 6.5 in speaking, he will not be eligible to take the PLAB
exam - even if his overall score is 7 or above.

The IELTS can be taken even while the candidate is still a medical student, although it
should be keep in mind that the IELTS result is valid for two years. The candidate must
go on to take his PLAB exam within this two year validity period.

If a candidate gets less than the required band score, he will have to retake the IELTS.
He cannot proceed further to take the PLAB exam unless he has received the minimum
band score of 7. Furthermore, he is ineligible to retake the IELTS exam in the three
months following his current attempt.

Unfortunately, many students and junior doctors in our area have had a real problem with
this exam, with many continuing to get lower-than-required band scores even in their
second attempt. This exam should be taken very seriously by those who don’t feel
confident of their English skills and who don’t read, write or speak the language often in
their daily routines.

It should be kept in mind that the IELTS is an exam and like all exams, it has its flaws and
weakness which can be exploited to allow a candidate to get through in the end. The
candidate may pass the exam because he is feeling particularly sharp or confident on that
day, or because the examiner testing his speaking skills was easy-going and brought out
the best in him, or because he learnt some ‘tricks’ that got him through. While the exam is
eventually passed by virtually everyone, difficulty in passing this hurdle indicates a
deficiency in English language proficiency that has the potential to seriously harm the
candidate’s future prospects in the UK. Passing an exam and living in a place where good
English skills is a professional requirement, are two different things. If a candidate with
poor English skills manages to get through the IELTS, his deficiency in the language will
eventually come across in job interviews later on, where communication skills and
confidence are important standards of assessment.

Therefore, an overseas doctor should be very conscious of the fact that English is the
language of his professional instruction and in the UK, the language of social and
professional interaction (with everyone from patients to teachers to bus drivers). It is, as
such, his life-blood. He should therefore concentrate on improving it for this sake alone,
and not for the purpose of passing an exam like the IELTS. Improving on a language
takes time, and the earlier a medical student/doctor realizes how important this is to his
career and focuses on it accordingly, the greater his chances will be of attaining a level of

45
competency that will make the IELTS a minor exam for him, rather than the sink-or-swim
exam it has come to be in many parts of Pakistan.

THE PLAB EXAM

The Professional Linguistic Assessment Board exam, or PLAB doesn’t actually have a
linguistic component, otherwise the IELTS would not be required. Nevertheless, the
‘misnomer’ remains to describe an exam of a difficulty level between that of final year and
post-graduate (i.e., MRC) examinations. It has two parts - PLAB Part 1 & PLAB Part 2.

The PLAB is basically a registration examination that allows you to practice medicine in
the UK. In that sense it is similar to the USMLE Steps of the US system. However, there
are three important differences between the PLAB and USMLE exams:

• The PLAB exam is considered to be far easier, and less costly than the USMLE
exams.
• There are only 2 parts to the PLAB exam, not 3 like in the USMLE Steps (or 4 if you
count USMLE Step 3).
• The PLAB is a pass/fail exam. It makes absolutely no difference to your credentials if
you pass the PLAB by an extremely wide margin or just manage to get through by a
single mark. This is in contrast to the USMLE Step 1 and Step 2 CK exams, in which
a candidate’s scores affects the strength of his CV.

PLAB PART 1
The first part of the PLAB exam, the Part 1 is administered in a number of countries,
including Pakistan where it is held three times a year: in March, July, and November.
Currently, the exam cost 145 Pounds Sterling.

In order to be eligible to take the exam, the candidate must be a medical graduate (he
cannot give it before graduation) from a WHO-recognized medical college and also have
the minimum required IELTS score in hand during the time of application.
The exam consists of a 3 hour paper containing 200 questions. The questions are called
“Extended Matching Questions” or EMQs - which simply means they are multiple choice
questions with a variable number of possible answers to the questions posed of which the
best one is selected. The exam concentrates on the clinical subjects, not on basic
sciences. There are also a few questions regarding medical ethics, evidence based
medicine, epidemiology, and public health.

PLAB PART 2
This part can only be taken in the UK. Recently, the capacity of the PLAB 2 center in
London has been expanded enormously, and now the exam will be held several times a
month every month, throughout the year. Currently, the exam costs 430 Pounds Sterling.

The Part 2 is a examination of clinical skills - not a paper-based EMQ exam. The system
devised for testing the candidate’s clinical skills is called the Objective Structured
Clinical Examination, or OSCE.

46
When you start the examination, you will go to your first “station” in which you will be
given some instructions. It could be taking history from a patient there, performing an
clinical examination, or a number of other things. You will have 5 minutes to accomplish
your task and 1 minute of pause to think before each station. There are 14 stations in all,
with two “rest” stations – so the exam lasts a total of 96 minutes. The primarily skills
tested for are:
• History taking and diagnosis based on history alone.
• Proficiency at physical examination
• Communication skills with patients
• Management of emergency cases

REGISTRATION
In order to get a job as a doctor, you must be registered as one in the GMC’s register of
medical practitioners. The fee for registration is 155 Pounds Sterling.

Currently, there are 4 types of registration:

Provisional: Granted to those in the PRHO posts.

Limited: Granted to doctors who have just obtained their first supervised training posts. It
is granted on submission of the job contract the doctor receives from the hospital in which
he is hired.
Full: Granted to those who have passed PLAB, and worked for at least 12 months in a
supervised training post in the UK. With full registration, the doctor can work in any grade
in the NHS – it doesn’t have to be supervised.
Specialist: Granted to qualified overseas specialists.

Starting from the summer of 2005 (some sources say it will be from April 2005), the GMC
will introduce reforms on registration procedures for overseas doctors. It will abolish
limited registration. From then onwards, all doctors who have passed PLAB will be
granted full registration automatically.

This move has been warmly welcomed by overseas doctors in the UK. Currently,
overseas doctors need a job contract in order to be granted limited registration. The
problem was that it was difficult to get a job without the registration. There was, as a
result, a difficult Catch-22 situation in which you needed the job to get the registration, but
getting the job was difficult without having registration already. Therefore, the abolition of
limited registration represents one less hurdle overseas doctors have to contend with.

With automatic full-registration after passing PLAB, there will probably also be a change
in the nature of clinical attachments. Previously, doctors who passed the PLAB and went
on to do a clinical attachment could only be passive observers. With full registration,
however this will probably change as they’ll be allowed to practically demonstrate their
clinical skills. (Clinical attachments are explained in the next section)

FINDING A JOB
After securing the minimum 7 band score the IELTS exam, passing the PLAB exam and
getting registered, the next step is to find the first job. This is the hardest part of the entire
47
process. As already mentioned, the job situation in the UK for SHO posts is exceedingly
difficult.

Jobs are advertised in the careers/job-opportunities sections of the British Medical

Journal (BMJ) in Lancet (another reputable medical journal) and the NHS Careers
Website. The jobs are then applied to as per the instructions in the advertisement.

There is a very important point to note here. Jobs are advertised in “seasons” – in that
most SHO posts start in February and August and advertisements for these posts start to
appear a couple of months before the jobs start. For example, advertisements for jobs
starting in August start appearing from April onwards. Therefore it is very important that
you plan your move to the UK keeping these seasons in mind. Arriving after a job season
is over will make it very difficult to find anything better than a locum or trust grade job.

Another point to note is that with the introduction of the FY2 in August 2006, the job
season will only come around once a year. Since FY2 posts last a year, there won’t be
any openings for new FY2 posts until that one year is over.

HOW TO IMPROVE YOUR CHANCES

Whenever there is intense competition for jobs in any field, not just medicine, the
fundamental principle for success is to be amongst the best.

If there are as many as 1000 job applicants for a single post (and this indeed has been
reported to be the case in many instances), the consultant who is hiring you must have a
reason to choose you over the other 999. The first point to remember is that SHOs
actively contribute to the NHS. They are not just taking from the system by obtaining a
valuable training experience, but they are also giving back to it by rendering their own
expertise. Therefore, when a consultant sits down and goes through a stack of
applications and CVs, he is looking for someone who can do a very good job as an SHO.

The key to improving your chances then is to convince this consultant that you will be
able to do the job better than everyone else who has applied.

In order to do this, you must first know which credentials are highly valued and sought
after in applicants to the SHO post and then strive to obtain them:

GROWING YOUR CV – THE CONCEPT

Most doctors who go to the UK have an MBBS degree and a PLAB pass - and that is all.
These two are the only pieces of evidence documenting their credentials. It is not
surprising then that most doctors who go with little else on their CV besides these two
accomplishments find it difficult to get jobs. A medical degree and a PLAB-pass are the
minimum acceptable criterion needed just to apply for SHO posts in the first place.
Having only this, and nothing more will not make you competitive. The consultant hiring
you must have a reason to choose you amongst the other hundreds of applicants – all of
whom also have medical degrees and PLAB passes.
48
“Growing you CV” is an important concept that was covered in some detail in a BMJ
Careers issue in June 2004. The principle behind it is to work diligently at acquiring
medically-related, documentable credentials that can be included in your CV as evidence
of your ever-increasing skills (and hence, worth) as a committed professional.

GROWING YOUR CV – AS A MEDICAL STUDENT

The process of growing your CV starts in medical college. There are numerous things a
student can do that can be placed in his CV years later when applying for jobs.

The Community Medicine research project is a wonderful opportunity to familiarize

yourself with Research Methodology. If you work very hard at it and do the job properly,
you stand a good chance at publishing your work in a medical journal. It doesn’t have to
be an internationally indexed journal. A local medical journal will do just fine. After all, no
one expects students to produce original research material of an standard that attracts
the attention of professional researchers and clinicians. The acceptance and publication
of your work while still a student will say a lot about your dedication and application of
basic research methodology so early in your career and this will add immensely to your
CV.

Probably the best investment a student can make is to become an actively participating
member of the International Federation of Medical Students Association (IFMSA).
This can open up a world of opportunities for you. As a member, you will be able to
participate in countless workshops, conferences and seminars around the world – which,
of course includes Pakistan. There will be other opportunities as well. For example, I
myself had the chance to be a reviewer for the World Medical Association’s
Undergraduate Manual of Medical Ethics. The manual is available now in medical
colleges throughout the world, and my name is in it. When I put this down in my CV, the
consultant reading it will know that have at least a rudimentary grasp of Medical Ethics as
well as the relevant language skills needed to review such a piece of literature. I was only
able to know about the opportunity because I am an IFMSA member. This career manual
you are reading right now is itself a credential that will go on my CV and add to it, and
again, it is being done in my capacity as an IFMSA member.

During your time as a student, you should avail each and every opportunity to grow your
CV. Take part in workshops, attend seminars, organize medical events – and try to learn
as much as possible from these experiences. Don’t do it just so you have something to
write in your CV later on. The CV after all, is a reflection of your professional self and not
just a laundry list of accomplishments. The attitude of doing something just for the sake of
the CV is unprofessional in itself and such an attitude will not take you far, even if it does
manage to get you your first job.

GROWING YOUR CV – AS A HOUSE OFFICER

The time spent as a house officer is often wasted. Little if any studying is done, and after
the novelty of working in a hospital as a doctor wears off, most doctors just do the
minimum amount of work expected of them. After settling into the house job, the doctor

49
can use his valuable 12 months doing a number of things like audits, research, paper
presentations, and courses.

Audits.
Simply put, an audit is a study undertaken to determine whether any component of a
health-care delivery system is functioning optimally or not. An audit is not the same thing
as research. In an audit, no new medical knowledge is gained – the focus is on the
medical system itself and not the science behind it.

To give an example - an audit was carried out in the Camden and Islington Community
Health Services NHS Trust, to assess how many patients met their first appointment
scheduled with their psychiatrists. The audit found that patients who had to wait more
than a month for their appointment date usually did not come at all. Based on these
findings, the audit recommended that ‘party clinics’ be held in which around 10 patients
would have a joint session, thereby introducing the psychiatrist to the patients before
‘real’ one-on-one sessions could be initiated. A second audit was done to follow up the
effectiveness of the recommendation, and it was found to work.

Audits are given great importance in the UK and are seen as the main tool to maintaining
and continuously monitoring the standards of health-care delivery. A doctor having
conducted several audits would be helping his CV immensely. It may not be easy to
conduct a audit in a hospital that does not have the proper infrastructure or well-
established inter-departmental communication, but an effort to overcome such difficulties
is worth attempting. Most UK graduates have conducted several by the time they are
SHOs and every attempt must be made by an overseas doctor to have several audits in
his CV when he applies for jobs in the UK.

For more information on audits, you can download the “Principles of Best Practice in
Clinical Audit” published by the National Institute of Clinical Excellence in the UK - a very
comprehensive document (some 200 pages) and available free online. It is the
authoritative document on audits.

Research.
A house officer will have much greater access to patients and as a result will be in a
much better position to do small clinically oriented research projects. If that is not
possible, any other small research will do – it could be a retrospective study. However
some research should be done during this time. As previously mentioned, published
research adds dramatically to your CV, and by the time you enter the house job, you
should be in a position to elevate the standard of your research skills.

GROWING YOUR CV – AFTER THE HOUSE JOB

In a Careers BMJ article dated 16th November, 2002, overseas doctors aspiring to come
to the UK were given the following advice:

“Once you have decided to come to the United Kingdom, don't waste valuable
time in gathering postgraduate or service experience in your own country— the
50
 sooner you make the move, the better. The reasons for this are twofold.
Professionally, you are not too far down a particular career path and so are in a
better position to choose a specialty that offers the best chance of progress at
that time. Socially, you are more likely to be free of the responsibilities that come
with age and so are more ready to accept, for example, an academic position that
may be good for your career but often brings a poorer salary.”

This may have been sound advice back in 2002, when the job situation had not yet
reached the levels of difficulty seen now.

Dr. Elitham Turya, a Consultant in Child Health, contributor to Careers BMJ, and author of
the book “Your Career After PLAB” wrote to me with the following advice:

“Work in Pakistan for about 2 years. Use the time to do one or two short research
items and 2 or 3 audits to describe in your CV. Most doctors will have MB BS
and will have passed PLAB. So why should one candidate and not another be
picked? The audits and research (short items- a few months’ works, could be
retrospective study) will improve your CV.”

It seems that currently, it would be better to stay back and “grow the CV” in order to
improve your chances of getting a good post in the UK.

Therefore if possible, a doctor should enter the post-graduate medical system in Pakistan
after the house job and work there for a year using that time to further grow his CV. If it is
not possible to start working immediately as a post-graduate doctor, then the “extra” one
year could be spent in a non-paid attachment with a hospital. During the additional one
year, more research studies can be done (this time, more substantial and demanding
ones), more audits, more presentations, with more conferences and workshops attended.
All this will go straight into the CV that will as a result become considerably stronger
compared to that of the doctor who went straight to the UK after his house job.

Workshops.
The College of Physicians and Surgeons of Pakistan (CPSP) holds workshops on a
regular basis (see the Pakistani section of this manual for more information on these
workshops). The workshops last 3-5 days and provide good credentials, all of which will
look good when added to the CV.

The CPSP offers workshops on “Computer and Internet Skills”, “Research Methodology,
Biostatistics, Dissertation Writing”, “Communication Skills” and ”Basic Surgical Skills”.
The CPSP provides doctors attending these workshops certificates to attest to their
participation.

Membership Exams.
If the doctor spends an additional year after the house job, he can avail that time by
studying for Part I of the membership examinations. If he works hard, then by the time he
is ready to go to the UK, he should be able to pass the first part of the Royal College
membership exam of his specialty. This is a great addition to the CV, and quite
achievable if he is able to stay back an extra year after his house job.
51
Therefore, by firmly adopting the concept of “growing your CV”, a doctor who goes to the
UK two years after he graduates should have (if he works very hard) the following on his
CV when he goes to the UK:
• 2-3 Research articles
• 2-3 Audits
• 2-3 Workshops attended
• 2-3 Paper Presentations
• Part 1 of the Membership exam

This is compared to the those doctors who only have the minimum criteria when they go
to the UK: a medical degree and a PLAB pass.

GROWING YOUR CV – UPON ENTERING THE UK

The first thing you’ll need to do upon entering the UK is to complete the PLAB by sitting
for the PLAB 2 exam, so you must organized your schedule accordingly. If you have
studied and are confident enough of your knowledge, then you should sit for the first part
of your membership exam.

Upon finishing these exams, you should start your clinical attachment.

Clinical Attachments
A clinical attachment is a period of time where a doctor is allowed into the hospital as an
observer. He can attend the rounds, clinical meetings, ask questions, see how things
work, etc… A clinical attachment can last from 6 weeks to 4 months. It is unpaid (in fact, a
few trusts in London now require payment) and accommodation is usually not provided in
the hospital – even if it is, you’ll most probably have to pay for it.

Currently, the doctor isn’t allowed to do any practical clinical work - although with the
change in the GMC registration policies (in which doctors are granted full registration after
passing the PLAB) this may change.

A clinical attachment provides a formal, supervised, hands-on introduction to the NHS

system and is a chance to make a good impression on a consultant who can later act as
a reference. Both are a major boost to a doctor’s CV.

Clinical attachments went from being considered a favourable addition to a doctor’s CV a

few years back to being practically indispensable. For overseas doctors, getting a job as
an SHO is next to impossible now without a clinical attachment. As a result, the demand
for clinical attachments has now approached the demand for jobs. Most overseas doctors
new to the UK, apply for clinical attachments before going on to apply for jobs.

Resultantly, it has become very difficult to secure a clinical attachment and it is strongly
advised that an overseas doctor secure a clinical attachment for himself before coming to
the UK.

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It is worth emphasizing this point again: Getting a job without exposure to the NHS is
extremely difficult with the current job situation. Recently, it has been observed that
doctors coming to the UK spend months trying to secure an attachment. Doing a clinical
attachment provides no sure guarantee of job immediately afterwards, and the doctor
may well be jobless even after having done 2 or 3 clinical attachments. It is only logical
then that the time spent trying to secure a clinical attachment should be spent in the
home country, where there are no problems with living expenses or accommodation.

There is no standard, formalized way of acquiring an attachment in the UK. Currently all
attachments are organized by personal, direct interaction with a consultant who will
ultimately become your supervisor and be the one responsible for you. It may not be the
consultant who you first approach, but someone else who can in turn approach the
consultant on your behalf. It is ultimately all about getting the consultant’s attention and
convincing him to allow you to be ‘attached’ to him for a period of time.

There have been a few trusts that recently decided to centralized and formalize the
process of clinical attachments. The Calterdale and Huddersfield Trusts for example
released a Clinical Attachment Policy statement in November 2004 in which they decided
that all further applications for clinical attachments be directed to their Post Graduate
Medical Education department, who would in turn contact the relevant consultants. The
introduction of a standardized system of processing clinical attachment applications may
be hurried through due to the immense demand for them. The Calterdale and
Huddersfield Trusts have made a start, but it is not sure how many others will follow suit,
and its is also not clear if doing so will remove the need (or effectiveness) of appealing
personally to a consultant.

Since clinical attachments have practically become a pre-requisite to a job, it is important

to understand how to obtain one, how to conduct yourself when doing one, when to apply
for one, how much it will cost, etc… Such detail is beyond the scope of this manual, but it
should be appreciated by the reader that every effort must be made to secure a clinical
attachment and due attention must be given to it when preparing to leave for the UK.

Courses.
There are a number of courses offered in the UK you would do well to include in your CV.

For those planning to go into surgery, the ATLS, Advanced Trauma Life Support, the
Basic Surgical Skills Course (BSS), and Care of the critically ill surgical patient
(Ccrisp) Course are all good additions to the CV. These courses cost around 400-500
Pounds and last for 2-3 days. Due to the expense involved, it is unusual to find an
overseas doctor applying for his first job with more than one course in his CV. These
courses are, however, a good investment and it is worth taking another one after you
have obtained the first job and have some more money in your hands.

For the medical specialty, the ALS, Advanced Life Support Course is being taken by
overseas doctors in increasing numbers. It also costs around the same amount, and lasts
for 2-3 days. There are not many other courses in the medical specialty suitable for
doctors wishing to enter the NHS at the SHO level, so taking this one course would be a
good investment.
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PRESENTING THE CV
With little time to spare in his busy schedule, and with hundreds of CVs to look at, the
consultant will literally not spent more than 60 seconds looking at your CV. However your
CV is you. It is a record of your life – it describes how well-qualified you are and why you
are the best applicant for the job. When writing your CV, make sure that whatever is in
those 5-6 pages is presented so well, and so clearly that it jumps out from the page to
capture the reader’s attention, causing him to pause and consider you as a serious
contender.

Perfectly good credentials that may earn an individual the job may be wasted if they are
tucked away in some corner of the CV where it might escape the reader’s attention. The
CV should not so much be written as designed. It has become something of an art and is
a skill that you should learn well. Sometimes, you may have to apply for a job in which
some of your credentials will be more important that others, in which case you would help
your chances by sitting down and redesigning the CV so that it is optimized for that
particular job.

There is no one correct way to write a CV, although there are many incorrect ways.
Although certain basic rules do apply, do not think there is one format out there that
maximizes success. Keep asking yourself if there is anything you could do to present
your credentials in a better way.

It must be emphasized however that if a candidate comes to the UK without any

credentials, experiences, or qualifications to write in his CV, then any amount of tinkering
and designing will not change that fact.

THE JOB INTERVIEW

When a consultant decides that he likes what he sees in your CV, he will short-list you for
the job and call you for an interview. He will also call a number of other doctors for the
same post. Only one of them will get the job, and it is the interview which decides who
that one person will be.

In the interview, the consultant(s) may ask you some medically-related questions, but if
you have managed to come this far, what he is really assessing is how you present
yourself. If you have a great CV with a long list of qualifications, but you comes across in
the interview as unpleasant, rude, or too timid and lacking in confidence, the consultant
not be inclined to choose you.

You must present yourself well and come across as a confident, competent, and likeable
person. These are after all, qualities any patient would want to see in his doctor and
therefore are the traits consultants are looking for as well.

The interview is also a time where your communication skills will be given careful
attention. If the consultant feels you have poor communication skills, it will be a big blow
to your chances of landing the job. This again emphasizes the need to be very well
versed in the English language. As previously mentioned, passing the IELTS is by no
54
means the end of the demand you must make on your English language skills. You must,
in this highly competitive time, by very proficient in the language.

55
 ---- SECTION C ---- POSTGRADUATE MEDICAL

EDUCATION IN THE USA

INTRODUCTION

SOME IMPORTANT TERMS AND CONCEPTS

The first term you should know is IMG, or International Medical Graduate also known
as an FMG, or Foreign Medical Graduate. You are an IMG to the relevant American
authorities if you have graduated from a medical college outside of the US or Canada.
This has no bearing on your nationality. You could be an American and still be an IMG if
you have gained your medical degree outside the US or Canada. Indeed, a non-American
who has attended medical college inside the US or Canada, will not be considered an
IMG.

So a Pakistani, Indian, Malaysian, Saudi, Briton and even an American who graduated
from a medical college outside the US or Canada is an IMG.

Another important term is GME, or Graduate Medical Education. This refers to further
medical training in the US after medical school that will, after its completion, allow the
trainee to practice medicine independently. This is, in other words, post-graduate medical
training, or as we popularly know it in Pakistan, specialization.

In America, the specialization, or GME, is pursued by working as a resident in a

program. For our purposes, a program can be understood as a hospital that has an
active teaching element incorporated into its setup. A resident is the doctor who is
working in such a hospital. The period of time of your further training, i.e., your
‘specialization’ is called your residency and it can last from 3 to 7 years depending on
which field you’re specializing in.

There are many fields, or specialties but practically speaking, there are just a few
specialties that IMGs have a realistic chance of securing these days. The most common
specialties IMGs are accepted into are Internal Medicine and Family Practice, which
together account for about 60% of all the residencies that IMGs are accepted into. Most
other specialties are difficult (not impossible) to get into. In Dermatology, for example,
only 1% of all residents are IMGs.

Basically, the residency is an intensive period of training at the end of which you will be
capable of practicing medicine without requiring the supervision of senior doctors. After
completion of the residency in your specialty, you may choose to pursue a subspecialty.
For example, if your specialty was Internal Medicine, then you could sub-specialize in
Cardiology or Gastroenterology to name just two possible subspecialties. Usually, a
person who enters a program for a subspecialty is called a fellow, and he is said to be
doing his fellowship.
56
The residency is a paid job. You will be working for the hospital and in return they will
train you and pay you between 35 to 40 thousand dollars a year. This much money is
adequate to live comfortably on and support a family. Therefore, when a person starts his
residency, he does not have to worry about finances if he is sensible with his money.
When an IMG secures the residency, he is offered a long term contract lasting several
years, so his future with that program is secured for at least 3 years, and he does not
have to worry about being removed from the residency during this time unless he
suddenly becomes grossly incompetent.

A short history of how GME in the US evolved is very useful in understanding most of the
terms you’ll encounter in your journey. Since the USMLE process is so long, a hopeful
candidate who comes across an unfamiliar term or acronym in a newsletter, online forum,
application form, bulletin, or the hundreds of websites related to the USMLEs, may start
to think that he’s discovered a deficiency in his knowledge that may prevent him from
maximizing his potential. The purpose of the proceeding section is to avoid this potential
blow to a candidate’s confidence. By viewing the GME process in its historical context, its
different components make a lot more sense, and acronyms like NBME, ECFMG, FSMB,
FLEX, or FMGEMS will not intimidate you when you know exactly what they are.

HOW IT ALL STARTED

In the mid 1950s, the healthcare sector in the US started expanding rapidly and gave rise
to a large demand for junior doctors. This demand was partly met by foreign doctors who
started coming to the US for further training in increasing numbers. They would not only
receive further medical training, but also provide invaluable services to the US medical
infrastructure.

However before foreign doctors were granted the license to practice medicine in the US,
the competency of those doctors had to be established. In order to make sure that foreign
trained doctors met the minimum standards of competence required to safely practice
medicine, a body was formed in 1954 called the Cooperating Committee on Graduates of
Foreign Medical Schools (CCGFMS). This body was formed in collaboration with a
number of other medical organizations like the AAMC, AHA, AMA, and FSMB. The
CCGFMS was told to come up with a system of assessing the overseas doctors in order
to distinguish the competent IMGs from the incompetent ones.

To this purpose, the CCFGMS put forward three basic requirements which can be
summarized as follows:

• The medical credentials of the foreign doctors must first be verified.

• The medical knowledge and clinical skills of foreign doctors should be tested. In other
words, a test (or tests) had to be devised that all foreign doctors would have to take
and pass in order to prove that they had the medical knowledge required to practice
medicine.
• The ability of foreign doctors to communicate properly in English must be tested.

57
These three basic principles, which were proposed 50 years ago are still followed to this
day, although the techniques used to enforce them have become increasingly
sophisticated over time.

Of these three recommendations, the area that underwent the most extensive revision
has been the second principle of testing the IMG’s medical knowledge as we shall soon
see.

HOW IT GOT GOING

When the CCGFMS put forth these recommendations, another body was created to
enforce them. This body was formed in 1956 and was called the Evaluation Service for
Foreign Medical Graduates (ESFMG). By the end of 1956, the name was changed to the
Educational Council for Foreign Medical Graduates (ECFMG) - a name you will come
across often.

The ECFMG went to work, and they soon developed a procedure of validating a foreign
doctor’s medical degree, which was the easiest part of the CCGFMS recommendations.

In order to implement the second and third recommendations of the CCGFMS, the
ECFMG worked together with an organization called the National Board of Medical
Examiners (NBME). As the name suggests, the NBME saw to it that the exams
administered by American medical colleges to its own students met the high standards
demanded of them. As such, the NBME had a lot of experience with medical exams, and
its help was sought by the ECFMG. Together these two created a standard set of exams
that would be administered to all foreign doctors who wished to pursue GME in America.
Along with a set of exams to test for medical proficiency, the ECFMG and NBME also
developed an English language proficiency test. If the foreign medical graduates failed
any of these exams, they would not be allowed to train further in America.

THE EVOLUTION OF THE ECFMG TESTS

In 1958, the ECFMG administered the test for the very first time. Only 298 doctors sat for
the exam. The exam was called the American Qualification Exam, or AMQ. An exam for
English was also introduced called the ECFMG English Examination. The next year, the
name of the medical exam was changed from AMQ to the ECFMG Examination. These
exams, both the medical and English ones, kept changing names and formats every few
years. There were other exams that ran side-by-side to these exams which were also
accepted. These were the Federation Licensing Examination (FLEX), and the NBME Part
I and Part II exams.

In 1981, the Test Of English as a Foreign Language (TOEFL) began to be accepted

as an adequate English language proficiency test. In 1984, the ECFMG medical exam
was altered and renamed to Foreign Medical Graduate Examination in the Medical
Sciences (FMGEMS). In the following years, a few more changes were made to the
exams until in 1992, a new exam format was introduced called the United States

58
Medical Licensing Examination, or USMLE which today, is the only exam administered
to foreign doctors wishing to pursue GME in the US.

(Note that the FLEX, the FMGEMS, and the NBME Part I and Part II exams are still
accepted by the ECFMG as valid. If you have taken them and passed, you will be
allowed into the US to practice medicine. However, it has been 10 years since these
exams have been discontinued, so the number of candidates having passed the FLEX,
NBME Part I or NBME Part II is going down. I only mention this point because it is
officially stated ECFMG policy to accept these examinations as proof of competency, so if
you come across such a statement anywhere, don’t start looking around for application
forms for the NBME, FMGEMS, or FLEX exams. They don’t exist anymore. The policy is
only stated for the benefit for those old graduates who might have given these exams
long ago, gone outside the US to practice medicine, and wish to return to the US to
practice.)

The USMLE was created by the NBME and another body called the Federation of State
Medical Boards (FSMB), which is a union representing all the different medical boards of
the States of America as well as some areas outside the US.

In 1992, when the USMLE was first introduced, the exam had three separate parts,
consisting of a Step 1, a Step 2 and a Step 3.

When the USMLE was being designed, the original blueprint on which basis the exam
was being constructed stated that an exam testing clinical skills (not just knowledge) was
also necessary. Such an exam had not already been designed at the time so work was
initiated to create one that would test the clinical skills of different candidates in a fair,
reliable and standardized way. As the USMLE exam was introduced in 1992, the FSMB
and NBME started working together to construct a reliable clinical exam. The end result of
years of research and designing was the introduction, in 1998, of the CSA, or Clinical
Skills Assessment. This exam tested the candidate’s clinical skills by using real-life
trained actors called standardized patients or SPs. This became an additional exam that
had to be taken along with the Steps 1, 2 and 3.

In June 2004, the CSA exam was replaced with the Step 2 Clinical Skills (Step 2 CS)
examination. While the content, type of examination, scoring, and length of time of the
Step 2 CS and the CSA are identical, one important difference is that in the Step 2 CS
exam, the candidate’s communication and comprehension skills in the English language
(as he interacted with the standardized patient) was actively tested as a separate
component of the examination. If the candidate fell short on the English proficiency
requirement built into the Step 2 CS exam, he will fail the exam as a whole. In most other
respects, the Step 2 CS and CSA exams are very similar.

Naturally, when the CSA exam was redesigned (and renamed to Step 2 CS) there was no
longer a need for the TOEFL exam. Resultantly, from June 2004 the TOEFL exam was
no longer a requirement. Another change that came with the evolution of the CSA into
Step 2 CS is that the exam which was previously simply known as Step 2 now became
known as the Step 2 Clinical Knowledge exam, or Step 2 CK.

59
Currently, when a candidate passed both the Step 2 exams, he will have been tested for
sound clinical knowledge with the Step 2 CK as well as for sound clinical skills with the
Step 2 CS. Note however that while these two exams complement each other in
assessing the candidate’s strength in clinical medicine, they are still separate exams.
They are applied to separately, with separate fees to be paid, and separate result cards
returned. Further, while the Step 2 CK can be taken in Pakistan, the Step 2 CS can only
be taken in the US (there are five centers, in five cities, where the exam is administered).

This discussion brings us to 2005, where the current set of exams that a candidate must
give to enter GME in the US are:

1. USMLE Step 1
2. USMLE Step 2 CK
3. USMLE Step 2 CS

THE USMLE AND RESIDENCY APPLICATION PROCESS

The entire process, which includes the exams, the traveling, and visa processing fees will
cost about Rs. 600,000 to 700,000.

Information on how to study for the USMLE or which books to use is deliberately not
included here for the reason that there are no universally agreed upon answers to these
questions. Furthermore, as generally agreed upon lists of recommended books keep
changing every year, any list included here would only be accurate only for a short while.

However, some basic principles contributing to success do apply:

Firstly, seek guidance on which books and other study materials to use by direct face-to-
face interaction with people who have achieved high scores recently. This is especially
true for Step 1 and Step 2 CK. Do not rely on advice from high-scorers who took the
exams two or three years ago. Such people would probably tell you themselves that their
information is out-dated.

Secondly, try to study in libraries (or have regular contact with people in libraries) where
there are people who have taken the Steps and others who are studying for the Steps. In
the Khyber Teaching Hospital library for example, candidates who have scored highly are
always available to advise on which books to use, which subjects to focus on, which
mistakes to avoid, how to time yourself, how to handle stress, etc… Candidates usually
return to the library after having done a Step and share their experiences with the people
there. As a result libraries like these contain a collective pool of knowledge on the various
aspects of the USMLE exams - not just about the right books, but about exam trends as
well. In the KTH library, this attitude of sharing knowledge and experiences about the
Steps has, over the last few years, inspired a lot of confidence in the existing knowledge-
base on how to score well in the exams. As a result, the number of high-scoring
candidates has increased sharply over the last few years.

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If you can’t study in such a setting, for whatever reason, repeated visits to such libraries
and groups will give you an idea how to study for the exams in a way that best suits your
capabilities and needs.

Consequently, the information on the Step exams below only provides a basic
introduction.

STEP 1
This is probably considered to be the most difficult of all the Steps. The subjects tested
are:
• Pathology
• Pharmacology
• Physiology
• Anatomy (Gross, Histology, Neuroanatomy, Embryology)
• Behavioral Sciences and Biostatistics
• Biochemistry
• Microbiology
• Interdisciplinary topics, such as nutrition, genetics and aging, molecular and cell
biology.

The Step 1 is an 8 hour, computer-based exam in which “Single One Best Answer
Questions” are asked. With the question asked, will be a list of 3 to 11 possible answers.
Some of the possible answers may be partially correct, but you’ll have to choose the best
one out of all the options. For example:

A 32-year-old woman with type 1 diabetes mellitus has had progressive renal failure over
the past 2 years. She has not yet started dialysis. Examination shows no abnormalities.
Her hemoglobin concentration is 9 g/dL, hematocrit is 28%, and mean corpuscular
volume is 94 µm3. A blood smear shows normochromic, normocytic cells. Which of the
following is the most likely cause?

(A) Acute blood loss

(B) Chronic lymphocytic leukemia
(C) Erythrocyte enzyme deficiency
(D) Erythropoietin deficiency
(E) Immunohemolysis
(F) Microangiopathic hemolysis
(G) Polycythemia vera
(H) Sickle cell disease
(I) Sideroblastic anemia
(J) Thalassemia trait

The correct answer being D.

The exam consists of approximately 350 questions which are divided into 7 sixty-minute
blocks. Once you start a block, you can attempt the questions within it in any order you

61
wish and can even change the answers, However, once you exit a block to move on to
the next one, that block is sealed and you can no longer change the answers in it.

Official “break-times” are included within the 8 hours of this exam. In order to maximize
your potential you need to make sure you don’t take breaks that are too long, or too early,
or too late into the day. To this end, you must be thoroughly familiar with the rules
governing these break times and try to simulate the exam at home before actually giving
it. Sample CDs are available that contain 40 blocks of questions which you can use to
simulate the exam several times over at home by solving 7 blocks in 8 hour periods. This
will not only build up stamina, but also help you decide how best to manage your breaks
in the exam.

For more detailed information, you should go through the Step 1 Content Description
and Sample Test Materials manual, which is updated and published annually by the
FSMB and NBMS and available online (for free). This manual includes many sample
questions, a detailed “syllabus” of the Step 1 content, and general advice on how to
approach the exam.

STEP 2 CK
To quote the Step 2 Content Description and Sample Test Materials manual, Step 2
CK includes test items in the following content areas:
• Internal medicine,
• Obstetrics and gynecology,
• Pediatrics,
• Preventive medicine,
• Psychiatry,
• Surgery,
• Other areas relevant to provision of care under supervision.

Most Step 2 CK test items describe clinical situations and require that you provide one or
more of the following:
• A diagnosis,
• A prognosis,
• An indication of underlying mechanisms of disease,
• The next step in medical care, including preventive measures.

The Step 2 CK is an 9 hour, computer-based exam in which “Single One Best Answer
Questions” are asked. Like the Step 1, with the questions asked, will be a list of possible
answers. Some of the possible answers may be partially correct, but you’ll have to
choose the best one out of all the options.

Step 2 CK contains approximately 370 questions which are divided into 8 sixty-minute
blocks. The same principles regarding working within a block and time-breaks apply to
the Step 2 CK just as they do to the Step 1.

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As with the Step 1, a Step 2 Content Description and Sample Test Materials manual is
published annually by the FSMB and NBMS and contains detailed information about the
content of this exam.

STEP 2 CS
This exam can only be given in the US, unlike the Step 1 and Step 2 CK exams which are
administered in Pakistan.

To quote the official USMLE website regarding Step 2 CS:

It is a one-day test that mirrors a physician's typical workday in a clinic. For 15 minutes
each, examinees will examine 12 “standardized patients," people trained to act like real
patients. Examinees are expected to establish rapport with the standardized patients,
elicit pertinent historical information from them, perform focused physical examinations,
communicate effectively, and document findings and diagnostic impressions. After each
encounter, examinees have 10 minutes to record a patient note, including pertinent
history and physical examination findings, diagnostic impressions, and plans for further
evaluation if necessary.

The cases will cover common and important situations that a physician is likely to
encounter in a general ambulatory clinic. Standardized patients are selected to represent
a broad range of age, racial and ethnic backgrounds. Other possible stations include third
party interviews (e.g., caregivers for children or frail elderly patients), telephone
encounters, and physical examination stations. Pelvic, rectal, and female breast exams
will not be part of the initial administration, but may be added later using mechanical
simulators.

When the first version of this exam, the CSA, was first introduced in 1998 as an essential
requirement for an ECFMG certification, the number of IMGs entering residencies in the
following Match dropped significantly. This was because at the time, this Clinical exam
was new and IMGs didn’t know how best to approach patients in an American healthcare
system. Since then however, many books regarding the CSA/Step 2 CS exam have come
out and currently, the exam is not seen to be particularly difficult after a month or two of
preparation.

Unlike the Step 1 and Step 2 CK exams, the result of the Step 2 CS is either a pass or fail
with no numerical score.

A WORD ON STEP 3
Step 3 is a 16 hour exam taken over two days in 8 hour testing periods. Step 3 is not
required to get the ECFMG Certification. Many American medical graduates take the Step
3 by the end of their first year of residency. The reason most IMGs take the exam before
their residency starts is because a pass in Step 3 is required to apply for an H1-B VISA. If
you don’t want such a visa, you don’t need to take it before your residency begins (visa
issues are explained below and the correlation between Step 3 and the H1-B visa will
make more sense then).

63
The Step 3 tests your ability to practice medicine in an unsupervised setting. In particular
it tests your ability to:
• Treat patients who come to you for the first time for treatment,
• Administer continued care (there is greater emphasis on this stage of patient care),
• Manage patients in an emergency setting.

WHAT SEQUENCE ARE THESE EXAMS GIVEN IN?

You can give the Step 2 CK and Step 1 in any sequence you wish. However, it is
strongly recommended that you take Step 1 before Step 2 CK. The Step 1 tests
knowledge in applied clinical sciences which lays the foundation for the subjects tested in
Step 2 CK. Therefore, it is logical to do Step 1 before Step 2 CK.

Recently a change in the eligibility for Step 2 CS has been introduced. Previously, it was
necessary to have passed at least Step 1 in order to be eligible for Step 2 CS. This
prerequisite has now been removed and a candidate can appear for the Step 2 CS as his
very first USMLE exam. The only limitation imposed on eligibility is that the candidate
must have finished the basic medical sciences (i.e., Anatomy, Physiology, Biochemistry,
Pathology, Pharmacology and Community Medicine) in his medical college/university.
Therefore, this exam can now be given while you are still a medical student. This change
has significant implications for the visa issues - which will be explained later.

The Step 3 is the last examination that you will take. You need to have passed the Step 1
and both Step 2 CK and CS before you are allowed to sit for this exam.

APPLYING FOR A RESIDENCY

Over the years, the process of getting a residency has become complicated. Books have
been written explaining the process. There are many steps involved, and a detailed
discussion of them is beyond the scope of this manual. For our purposes, a very brief
step-by-step sequence will be sufficient:

ECFMG CERTIFICATION
By passing the Step 1, Step 2 CK and Step 2 CS, you’ll apply for and receive your
ECFMG Certification. This certificate attests to the fact that you have the required
clinical knowledge and skills as well as the language skills to train in a residency program
in the US. You need this certification in order to work as a resident.

You can however begin the job application process before having attained your ECFMG –
in that you can start the application process on the strength of your Step I and Step 2 CK
passes, as it will be assumed that you will be giving the Step 2 CS in the near future.

ERAS
When applying to a residency position, the first step is to send all the required documents
to a service called ERAS, the Electronic Residency Application Service. The ERAS is
a service that provides a standardized, cost-effective means of forwarding applications
from the candidate to the different programs he is applying to. It is mandatory for all
applicants to apply via ERAS. This is how it works:

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Some documents (your CV and Personal Statement) are sent to ERAS by uploading
them directly to the ERAS website. Other documents (your photographs, examination
transcripts, letters of reference, and dean's letter) are sent to the ERAS headquarters in
Philadelphia by post or courier service. When these posted documents are received, they
will be digitally scanned and attached electronically to your application. Consequently,
your entire application for a residency position will be in an electronic format.

You will then indicate to ERAS which programs you wish to apply to, and ERAS will then
email your entire application to them. ERAS provides this service at cost that increases in
proportion to the number of programs that an applicant applies to.

On the 1st of September of every year, ERAS begins to send the applications (that have
been approved by the candidates as being ready to send) to the residency programs. It
will continue to send applications till November of the same year. Therefore, all
applications by candidates must be completed and given over to ERAS within this window
period between September to November.

It is strongly recommended that your application is complete and sent to the programs
as soon as ERAS starts sending them, i.e. 1st of September. The reason is that
programs tend to decide on who to short-list for the interviews (see below) quickly - so the
sooner your application reaches them, the better the chances are that you’ll be amongst
those short-listed for an interview.

THE INTERVIEWS
Around November, the program directors (those in charge of the program) short-list
candidates they feel are promising and call them for face-to-face interviews. This means
you’ll have to go to the US.

The interview “season” starts from November and continues till January. The programs
that short-list you for interviews will inform you of the fact, and you will then schedule the
interview somewhere in the interview season at a date which is convenient to you.

It is recommended that you schedule the interviews early in the interview season. If you
schedule the interviews late, there is a chance that the program has already decided to
hire applicants (who have come to the interviews before you) into all the available
resident slots. The sooner you meet the program directors, the better your chances are
that you’ll be offered a position.

It is a good idea to schedule interviews with programs you are most interested in
somewhere in the middle of your schedule. This way, by the time you are interviewed by
those programs, you’ll be oriented to the process, but at the same time not exhausted by
it.

Many people go to the US not just to give their interviews, but also to give Step 2 CS and
Step 3. However, it would be best if these exams are taken, and the results included in
the ERAS application before the interview season starts. Attaining the ECFMG
Certification (by passing Step 1, Step 2 CK and Step 2 CS) by the time you are first
65
applying will naturally strengthen your application. For that matter, a Step 3 pass by the
time of the interview season would also strengthen your application, especially if you are
seeking a “Pre-match” (see below) for an H1-B visa.

THE MATCH
Around the time you send your ERAS applications (i.e., early September) you will also
register online to participate in the National Resident Matching Program (NRMP), also
called “The Match”. The NRMP gathers what is called a ‘rank order list’ from both the
candidates and the residency programs. A rank order list submitted by the candidate lists
the programs he would like to join his in order of preference. At the same time, the
programs also send the NRMP a list of candidates they would like to hire in their order of
preference. Naturally, this list will be submitted after the interviews have taken place,
when both parties have met, assessed, and “ranked” each other.

The rank order lists (submitted by all the candidates and all the programs) are gathered
before a fixed deadline. Then, on a fateful day in March, a computer algorithm processes
the rank order lists and programs are matched with their candidates. A candidate will be
matched with one program (no more). For the program, the match result is binding in that
it cannot ignore the match result and decide not to hire you.

THE PRE-MATCH OFFERS

Sometimes a residency program may like a candidate enough to offer a position well
before the match (sometimes as early as November or December). Community-based
hospitals (i.e., those hospital not affiliated with a medical school) are more likely to make
such offers, but some University programs may do so as well. In general, unless a
candidate is very certain that he or she is a very strong candidate and stands a very good
chance of matching in a very good university program, the pre-match is a very good
opportunity to ensure a job rather than taking the risk of not getting matched. The down
side is that you may have to content yourself with a hospital that may not be your first
choice. Even then it has the great advantage of giving you a larger time interval (up to 6
months) to apply for your visa, increasing the likelihood that you’ll be able to have your
visa approved in time. Most of the Pakistani residents currently in the US would strongly
recommend accepting a prematch offer given the uncertainty of the visa situation these
days. An important point here is that if you do intend to accept a prematch, make sure
that you mention in your interview that you are open to prematch offers. Unless you ask
for it, they have no way of knowing. Having all your exam results in hand (Steps 1, 2 and
3) increases the likelihood of residency programs offering a prematch.

APPLYING FOR THE VISA

A few days after the match result is out (and you have been successfully matched), the
hospital you have been matched with will send you a letter of appointment. The
appointment letters from the hospitals are mailed on the third Thursday of March - the day
after the Match officially closes. Upon getting the letter, you will then apply for a visa (from
your home country) to work in the US. The problems associated with visas will be
discussed in detail later on. If visa problems don’t interfere, you’ll be able to reach the US
in June, and settle down to start working in your program from the 1st of July!

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IMPROVING YOUR CHANCES
Several factors influence your chances of securing a good residency. When IMGs reach
the stage at which they’re applying for a residency, they all have ECFMG Certification (or
are close to getting one), so candidates who apply to programs are selected on the basis
of other criteria. You can be a weak candidate, or a strong one and this will influence your
chances of securing a good residency.

The following factors improve chances of getting a good residency.

1. High Step 1 and Step 2 CK scores (not an easy task)

2. Research experience. (An original research article in an international medical journal
will be a very, very strong asset).
3. Elective experience in the US. An elective is a brief clinical or research experience
with a program in the US. It is taken only by medical students, not graduates. A
clinical elective helps a lot more because it proves you have worked within, and have
become familiar with, the American health care system – an strong asset for an IMG.
4. Strong letters of recommendations from American doctors who supervised you during
your elective experience.
5. A strong extra-curricular record. Programs prefer to have well-rounded candidates
who are also personally well developed alongside their professional qualifications.
6. Step 2 CS and Step 3 passes at the time of applying.
7. Impressing the people at the program (during your interview) as being a likeable,
intelligent, and over-all decent human being with strong grasp of the English
language.
8. Last but not least, in America (as is true everywhere) it’s not just how much you know
but also who you know. If you know someone in a residency program or a practicing
physician who knows people in a residency program, that just might be your biggest
asset. At times it is more useful than USMLE scores or letters of reference. Such a
person could intervene on your behalf and convince the program directors that you’d
make a great resident and that they should definitely hire you.

At the other end of the spectrum are factors that will actively hurt an IMGs chances of
getting a position in a program:

1. Low Step I and Step II scores.

2. Zero extra-curricular activities.
3. Personally not likeable and very poor English, both of which will come across during
the interview.

Basically, the people who hire a resident are looking for a person who is not only a
competent doctor, but who will also make a pleasant co-worker. If the candidate comes
across positively on both of these counts, his chances of getting a residency will improve,
and vice versa.

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 EXAMPLE OF A TIME-LINE FOR PLANNING THE STEPS
It is important to make sure that you give the Steps in an order that maximizes the
chances of securing a residency in the US. This requires careful planning and the
discipline to follow the plan through.

Keep in mind that the time-line proposed below is considered to be optimum in the sense
that it maximizes the chances of securing a good residency, but this should not be taken
to mean that deviating from this time-line will make it impossible to succeed.

To establish a reference point, the time-line below starts from January 2006.

STEP 1
Assuming that you graduate or finish your house job in January 2006 (the usual date for
students of Khyber Medical College), you should take the Step 1 after 7-8 months of
studying in August 2006.

STEP 2 CK
It will be difficult to begin studying immediately after your Step 1 because you’ll be tired
and more importantly, distracted by the wait for the Step 1 result. Lets assume you restart
your studies in mid-September, by which time you should have received your Step 1
result. For the Step 2 CK, 3-5 months of study is considered adequate, which brings us to
March 2007, at the latest for the Step 2 CK date.

STEP 2 CS
Let’s assume for now that the Step 2 CS is the third exam you’ll give (remember, it is now
possible to give it as the first exam, even while you’re still a student). Lets suppose there
are no visa problems and you are able to go to the US and take the Step 2 CS in May
2007 with the month of April spent studying for the Step 2 CS.

STEP 3
A month or two of preparation for the Step 3 should be enough so that you’ll be able to
give this exam in July, or August 2007 at the latest.

ERAS
With all the Steps done by August you’ll sit down, consult with seniors, make enquiries,
and think long and hard on making a very careful and realistic list of programs you feel
you have a good chance of getting into.

With this list in hand, and all your documents sent to ERAS by the time it opens on the 1st
of September, you’ll have a complete application to send to the programs.

THE REASONING BEHIND THIS TIME-LINE

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The basic aim of the time-line above is to have as have passed as many Steps of the
USMLE exams before ERAS opens in September.

It is worth stressing that at the very least, the Step 1 and Step 2 CK exams must have
been completed by July of the year you are applying. As explained previously, having
very good Step 1 and Step 2 CK passes at the time of applying will make the residencies
more likely to short-list you for interviews. Applying with only a Step 1 pass, even if the
score is excellent, is taking a risk. Furthermore, with only a Step 1 pass at the time of
applying, you’ll be very pressed for time because in the 6 months following July, you’ll not
only have to prepare your ERAS documents, but also study for the Step 2 CK, make
travel arrangements to the US, research and choose your programs, travel to interviews
in the US, and on top of all that find that time to take the Step 2 CK, Step 2 CS and the
Step 3.

It won’t make a lot of difference if you don’t have Step 2 CS and Step 3 passes by the
time ERAS opens. In other words, not having the Step 2 CS and Step 3 results by the
time of applying will not actively hurt your chances of getting interview calls, but on the
other hand, having them will actively help your chances. As the Step 2 CS and Step 3
are usually always passed by candidates who have very good Step 1 and Step 2 CK
scores, residencies assume that for such candidates, an ECFMG certification is only a
matter of time. This is why it is entirely feasible to apply with just Step 1 and Step 2 CK
passes and still expect to get good interview calls.

THE VISA ISSUES

Basically, a visa is a permit allowing you to enter another country, and in this discussion,
this country in question, is the United States.

If you are a non-US citizen, then you will need to have definite, stated reason for going to
the US. You will then apply for the type of visa that reflects this stated reason. In order to
classify the types of foreign nationals on the basis of the reason they are visiting the US,
the State Department of the US issues different types of visas. These visas are lettered
from “A” all the way to “T”, with every type having subtypes.

The A visa, for example, is for diplomats. If you want to go to the US in your function and
capacity of an ambassador, public minister, diplomatic or consular officer, or an
immediate family member (of all these diplomatic posts), you would need to apply for the
A-1 visa.

For our purposes, there are only four visas we need to concern ourselves with. They are
the H1-B visa, J1 visa, the B1/B2 and the F1 visas. If you come across any other visa
types in your USMLE journey, you may cheerfully ignore them.

Sponsoring: A program is said to sponsor a visa if it will take responsibility for you once
that visa is approved. This applies only to the J1 and H1-B visas.

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THE B VISAS
You need to go to the US in order to take your Step 2 CS exam as well as to attend the
interviews. In order to do this, you will need a “visiting” visa. There are two types of
visiting visas, the B1 and the B2. When you apply for these visas, your stated intention for
coming to the US is for business (in case of the B1 visa) or for pleasure (in case of the B2
visa). You can apply to either one for the purpose of going to the US for the Step 2 CS
and/or interviews. The B visa (be it B1 or B2) is the first visa you will need to apply for and
this is where most of the visa problems you may have heard about arise.

There are 3 types of B visas:

• A 6-month single entry visa – in which you’re allowed to go to the US once in a 6
month window period
• A 1-year double entry visa – in which you’re allowed to go to the US twice in a 1 year
window period
• A 5-year multiple visa – in which you’re allowed to go come and go freely to the US
within a 5 year window period.

The reason it has become increasingly difficult for people to obtain a B visa is because of
a long history of foreigners going to the US as a temporary “visitors” and then
disappearing from the radar to stay and work illegally in the US. This has become a huge
headache for the US State Department and Department of Homeland security, and in
response, they have become increasingly suspicious of financially poor B-visa applicants
from third world countries who want to visit the US as “tourists”. It is not surprising that the
visa officers will reject the application for a B-visa on the grounds that the individual in
question is considered a high-risk case who may not return from the US, but stay to work
there illegally.

Therefore, for quite a number of years now, applicants for B visas have the burden of
proving to the visa officer that they do intend to return to their country after concluding
their business in the US. The visa officer will assume that the applicant for the B visa is
going to misuse his B visa if it is granted, and it is the responsibility (or ‘burden of proof’)
of the applicant to convince him otherwise.

This visa has, in recent years, become the most problematic for those wishing to go to the
US for the Step 2 CS and/or interviews. It is on record that individuals who have taken
both Step 1 and Step 2 CK (and scored very highly) who wish to go to the US for their
Step 2 CS/Interviews have been rejected for the B visa . Naturally, this can be very
devastating for the candidate, who by that stage has invested not only a lot of money, but
time and great effort as well. After working and planning for years, their dream of going to
the US for further training can be killed by a visa interview that lasts less than 5 minutes.

There are certain factors that could help a candidate improve his chances of securing the
B visas. The basic principle behind the factors, is strong ties to the home country. If an
applicant has strong ties to his home country, it can be taken as proof that he will most
probably return to his country when his business is done, and not stay back in the US
illegally. Evidence of strong ties could include, proof of property and/or substantial assets
in the home country, immediate family in the home country, or good socio-economic

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position in the home country, etc… Whatever convinces the visa officer that you have ties
to your home country that you would not jeopardize by staying permanently (and illegally)
in the US could improve your chances of getting the B visa.

Note that I keep on using the words “could” or “can” when I talk about improving your
chances. The reason is that the experiences of our IMGs applying for this visa
demonstrate that there doesn’t seem to be any criteria that we can reliably use as a
guide. People with good home country ties have been rejected, while others will poor
country ties have been given the B visas. Similarly, people with great USMLE scores
have been rejected while people with less-than-good scores have been given the visa.
There is even a case of a bright young man who got 90s in both his Step 1 and Step 2
exam, went to the US on a B-visa to give his CSA exam, and came back. When the
interview season started, his B-visa had expired and he applied for another B visa to go
for this interviews but was rejected. Stories such as these have made the whole visa
issue very uncertain. Most people just leave it to fate, or God’s will, and leave it at that.

However, I don’t wish to give you the impression that the situation is hopeless. Far from it,
many people still get the visa. Furthermore, a lot of the people rejected for the B visa the
first time get it after the second, third or even fourth attempt. An initial rejection for the B
visa is not the end of the story. You can definitely reapply. The only problem is that the
processing for the visa can take several months, and an initial rejection can set your
whole timetable back. In many cases, this usually means that the individual will lose the
opportunity to participate in the match that year. It is therefore highly recommended that
you apply for this visa as soon as possible in your USMLE process, so if you get rejected
the first time, you can afford the time it takes to reapply.

This is a good place to mention Electives. As I said previously, an elective may be clinical
or research. In a research elective, you participate in a research study in a hospital or
medical university. A clinical elective involves you observing (not actually doing anything)
and studying medicine in the clinical environment of a hospital. In recent years, it has
become clear that such an elective (especially the clinical one) helps tremendously in the
whole USMLE process. For one thing, the elective experience is, in itself, a valuable
addition to your CV. Furthermore, the visa obtained for going to such an elective is the B1
visa. Electives are offered to medical students, not graduates. Therefore, at the time of
applying for such an elective, the individual will be enrolled in a medical college, which is
a strong proof of “ties to home country”. This is perhaps why medical students going for
electives have had a much easier time obtaining the B visa compared to medical
graduates. Now, if the visa you obtain for your elective is a is a 5-year multiple, that
means it will still be valid by the time you are ready to go to the US to give the Step 2 CS
and go for interviews. Nevertheless, it does not automatically mean that all other visa
hurdles are overcome, as we shall we in the section on J1 visas.

THE F-1 VISA

The F-1 is a student visa and when granted, allows you to join a university or college in
the US to pursue a certain degree. It is easier to get an F-1 visa approved than a B-1
visa. Therefore what we have seen happening in recent years (particularly in India), is
doctors with visa problems applying to colleges/universities in the US to study for the one
year Master of Public Health (MPH) degree. This MPH degree not only enhances an
71
IMG’s credentials, but also allows the IMG to travel to the US. While the visa problem
may be bypassed, the disadvantage of going by this route is the cost involved. Depending
on the college/university, a one-year masters degree can cost anywhere from $5,000 to
$40,000. Furthermore, if a doctor has yet to give his USMLE Steps, then it will become
very difficult for him to study for both his MPH degree and his Steps.

An alternative to applying for the F-1 on the basis of an MPH degree in a

college/university is the Kaplan USMLE courses. These courses vary in duration with the
longest lasting a year. If you enroll in a Kaplan USMLE course, you will be eligible to
apply for the F-1 visa. A further, obvious advantage is that attending the Kaplan course
mean you’ll be studying for the Steps. The downside is that the one-year course costs
approximately $10,000. Along with the cost of the course will be the living expenses you’ll
have to bear during your stay there.

THE VISA PROBLEM AND THE STEP 2 CS

In order to take the Step 2 CS exam, you need a B1/B2 visiting visa to travel to the US
where this exam is conducted. These days, the key to getting a visiting visa is to provide
demonstrable proof that you have business in the US you need to attend to. If you apply
for the Step 2 CS exam, you will be mailed the registration receipt for the exam, and this
will suffice for the “proof” needed.

Currently, most candidates apply for the Step 2 CS exam after their Step 2 CK. This was
usually around February or March of the year they were applying to ERAS. The problem
with this is that these days, visa processing and approval can take up to 6 months and if
you’re unlucky sometimes even longer. Therefore, a candidate applying in
February/March for a visiting visa was at risk of getting it approved at a time when the
interview season is over – causing him to miss his chance at a match that year.

Since the Step 2 CS exam can now be given even by medical students, the logical thing
to do is to apply for a visiting visa very early on in the USMLE process. Suppose, you
apply for the visiting visa in January 2006, around the time you start studying for the Step
1. In that case, even if your visa application process takes up to a year, it will still come
through in January 2007. Thereafter you can travel to the US when it is convenient for
you, without having to worry about missing interview dates – which are still 9 months
away.

Applying very early for a visiting visa also gives you the opportunity to reapply if your
application is rejected the first time (as it often is) and not miss your target Match year.
Often people who were rejected the first, or even second time got approved in their third
try.

To illustrate: suppose you’re aiming to participate in the 2008 Match. Let’s also assume
the visa processing time takes 6 months. If you apply in January 2006 and get rejected
the first time in June 2006, you will reapply immediately that same month. If your
application gets rejected a second time in December 2006, you will immediately reapply
yet again. If you’re lucky, you’ll get approved the third time and be allowed to go to the US
somewhere in the middle of 2007, where you’ll be right on time to take the Step 2 CS,
Step 3 and attend your interviews.
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Visiting visas are granted to medical students more readily than medical graduates so the
best time to apply might be in your final year of medical college/university.

If you obtain a 5-year multiple visa while still a student, you don’t have to worry any
further about visa problems when the time to take the interviews and Step 3 arrives,
about two years later.

On the other hand, let’s suppose as a final year student, you get only a 6-month or 1-year
entry visa (and avail it to go to the US to take and pass the Step 2 CS). Such a visa would
expire by the time you were ready to go for interviews and Step 3. In that case, after
passing first the Step 2 CS, then Step 1 and Step 2 CK, you should immediately apply for
your ECFMG certification and register for the Step 3 exam and apply for a visiting visa on
the basis of your Step 3 registration receipt. It is hoped that having already previously
received a visiting visa (even if was just a 6-month or 1-year duration), the chances of you
getting a visa a second time to take your Step 3 and go for interviews will be good
(although this may not always be the case). Even if this second visa is only a 6-month
entry visa, it would be adequate to go to the US to take the Step 3 and attend interviews.

THE H1-B VISA

The H1-B visa is given to “Specialty Occupations, DOD workers, and fashion models”.

Plainly put, the H1-B is a work visa. It allows you to enter the US and use your
professional credentials to earn a living. In order to do so, you need to secure an
employment first, and in our case, the employer will be a hospital program where the
doctor will also be trained. This also explains why IMGs who wish to be considered for a
H1-B visa have to pass the Step 3 first. The Step 3 is evidence of your ability to practice
medicine in an unsupervised setting. Before the program hires you, it wants proof you can
do the job. Not all programs sponsor IMGs for H1-B visas so if you’re interested in getting
an H1-B visa, you have to do your research and find out which ones do. In general
community-based hospitals are more likely to sponsor H1-B than university-based
hospitals but there are many exceptions.

The H1-B visa is widely preferred by IMGs for the reason that it allows the IMG to file an
application for a Green Card (a permanent residence status) in the US. In order to apply
for a Green Card, your employer has to sponsor you for one. The number of residency
programs that sponsor their H1-B workers for a green card is small, the reason being that
the residency is a “training” position rather than an “employment” one.

The H1-B is valid for 6 years. This allows IMGs on H1-B visas to apply for a job after their
3-year residency is over with another employer who will sponsor a green card for them.
Since by the time you complete a residency, you’ll be a well-qualified doctor, getting jobs
in such places is not too difficult.

There are other clear advantages of the H1-B over the J1. Firstly, residents on the J1
visa have to overcome the hurdle of the “two year requirement” (see below) which is
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something H1-B residents have to worry about. Secondly, residents working on the H1-B
visa can travel back to their own country (for vacations or whatever) freely, without having
to renew this visa when returning to the US. By contrast, residents with the J1 visa who
visit their country have to renew the J1 visa when they are returning to the US. There is
always the possibility of the J1 renewal being rejected - it has happened. As a result, the
J1 holders find themselves a less secure than the H1-B holders. Thirdly, once an
application for an H1-B visa is made by the employer, it is almost never rejected by the
American Embassy. The H1-B visa is issued with the presumption that the H1-B worker is
filling a vital skilled worker gap for which an American worker of similar credentials cannot
be found. Therefore, it is in the interest of the US to issue such a visa when an employer
in the US asks for it. By contrast, the concept of the J1 visa, as we shall see, carries no
particular influence on US interests, and as such can (and has been) rejected.

The H1-B visa is applied for by your employer, not by you. When you been matched with
a program that will sponsor you for a H1-B visa, it is up to them to apply for the H1-B visa
on your behalf. In order to be eligible for H1-B sponsorship, you need to have your Step 3
result (passed, of course), no later than (and sooner if possible), March of the year the
residency starts. This is important to ensure that the H1-B visa application has sufficient
time to get processed before the residency actually begins. It can take as long as 6
months to process. However, a service called premium processing is in place which
guarantees that your H1-B application will be processed in under 2 weeks for a fee of
$1000 dollars. If you find a program that sponsors you for an H1-B visa, and the
application is processed and approved in time, then you can go and join the program as a
resident on the first of July of that year.

THE J1 VISA
In 1961, the US Congress passed an act called the “Mutual Educational and Cultural
Exchange Act.” According to the US State Department: “The purpose of the Act is to
increase mutual understanding between the people of the United States and the people
of other countries by means of educational and cultural exchanges. International
educational and cultural exchanges are one of the most effective means of developing
lasting and meaningful relationships. They provide an extremely valuable opportunity to
experience the United States and our way of life. Foreign nationals come to the United
States to participate in a wide variety of educational and cultural exchange programs.”

In order to come to the US for the purpose of “participating in educational and cultural
exchange programs,” the J1 visa was created. Certain institutions were given the right to
sponsor J1 visas. Of the many such institutions, many training hospitals were also
included.

A person coming into the US on a J1 visa would be an “exchange visitor”, i.e., he has
come to acquire skills in the US that he will take back with him to his own country once
the period of training is over.

The underlying principle of the exchange program is that the US allows third world
countries to benefit from Western expertise by allowing them to send professionals to be
trained further for a fixed period of time. When this time is over, the professional will go
back to his home country to share and spread the skills he has acquired. If this principle
74
were actually applied, it would benefit the home country immensely, because every year
we would have hundreds, if not thousands of highly trained doctors coming back to their
country instead of going out.

In order to ensure that the exchange visitors actually do go back home after the training is
over, the J1 holder is subject to a Two-Year Foreign Residency Requirement. This
requirement insists that the J1 holder return to his home country for at least two years
after the period of training is over unless he receives an exemption for this requirement.
If the J1 is seen by most IMGs as undesirable, it is mostly because they don’t wish to face
the prospect of being forced to return to their own countries.

The most common way the exemption to the 2-year requirement is met is to be employed
in a medically underserved area in the US. What scares most doctors who try to exempt
themselves from the 2-year requirement is that these “underserved” areas may be in the
middle of nowhere. After all, the area would be medically underserved for a reason – few
doctors want to practice there. Furthermore, you may not get the appointment to an
underserved area in the first place, and if that happens to be the case, you will have no
choice but to leave. The exemption from the 2-year requirement therefore is a huge
source of worry for many doctors on the J-1 visa when the time to deal with this problem
draws near.

When you are matched with a program that sponsors the J1 visa, they will send you a
letter of appointment. You will apply for a J1 visa at the American Embassy on the
strength of this letter of appointment. Remember, the match occurs on the 3rd
Wednesday of every March and the residency starts on the 1st of July, which is 3 and a
half months away. A potentially serious problem arises here: three and a half months may
not be enough time to process the J1 visa application. There is no premium processing
system in place for the J1. Such an application can take as long as 6 months. Therefore,
if it takes more than 3 and a half months, you’ll miss the start of your residency.

This in fact is precisely what has been happening in the last few years. Many applicants,
armed with a letter of appointment sponsoring a J1 visa have gone to the US Embassy
only to find themselves months later in no-man’s-land their residency start date has come
and gone while their J1 application is still pending. Whether the candidate lost the
residency over this depended on the generosity of the program itself, but as can be
expected, the increased trend of prolonged J1 processing time has tried the patience of
many programs. The program suffers greatly itself, because it has to redistribute the
existing workload on its already overworked resident population. This has led to a
disturbing trend in that programs with bad J1-processing experiences have stopped
accepting graduates from countries (like Pakistan) where potentially prolonged clearance
of the J1 visas meant a possibility of missing the start of the residency. The program
directors cannot be blamed for treating Pakistani applicants with some caution. Their
primary responsibility is to their program, and they must do what is best for the program.
If this means accepting less “high-risk” doctors into their program, then so be it.

The delayed processing time of the J1 visa for some doctors is not the only problem to
arise in the last few years. It appears that the J1 visa has been out-rightly rejected by the
American Embassy. This perhaps is the most devastating blow of all. The very last hurdle
75
is the J1 visa. After all the Step exams, all the interviews, all the hard work, money and
time invested, the very last thing an IMG requires is for his J1 to be approved so he can
go work in the US. It is not known how many doctors have faced such a predicament, but
its rising incidence has prompted the Association of Pakistani Physicians of North
America (APPNA) to write a petition to the US State Department in July of 2003 (when
residencies started and the J1 visa status was apparent). The subject of the petition was
“Significant Rise In The J1 Visa Refusals To Pakistani Phycisians”. The petition
mentioned the following, among other, points:

• In the previous month of June 2003, there has been a significant rise in the refusal of
J1 trainee visas to Pakistani physicians. These physicians have completed an
exhaustive process of taking the required qualifying tests, have received ECFMG
(Education Commission on Foreign Medical Graduates) certification, were
interviewed and selected in a US Residency Program in an accredited training
hospital, were issued the contracts by the hospital and had received the necessary
paperwork from the ECFMG and the Pakistani Government for an Exchange Visa
Program. The final step was to get a J1 visa from the US Embassy in Islamabad to
proceed to USA for training. Traditionally the residency-training year starts on July 1st
of every year.
• We know of at least twenty-five such physicians who were turned down at the
eleventh hour. There are probably many more.
• The reasons given to the visa applicants, through the information received by us,
were varied, but universally flawed. Reasons ranged from unsubstantiated technical
reasons, to "USA does not need any more doctors", to not enough social ties for the
individual to come back to Pakistan. It is to be noted that the J1 visa is issued
specifically for the purpose of returning to the country of origin.
• We strongly believe that all the reasons given (for rejecting the J1 visas) are trivial at
best and give the impression of a concerted policy to deny visas to aspiring
physicians from Pakistan. We believe that the policies are not enforced with same
level of strictness to physicians from countries other than Pakistan. As such they are
discriminatory.
• (This) will also deter the future training program directors to select physicians from
Pakistan as they may again face similar denials of visas.

At the time of writing this manual, the direction of this trend is unclear. It will be evident
from the Match of 2005 whether the situation has worsened or improved since it was first
noticed in 2003.

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 CONCLUSIONS

The following general recommendations are derived from advice given to me by

accomplished seniors whom I’ve had the pleasure to have conferred, and in some cases,
been friends with.

These recommendations apply most accurately to the medical institute I am currently a

student of myself, namely Khyber Medical College (KMC), Peshawar. However, the
general principles are applicable elsewhere and may be just as relevant in other
institutions as well.

A FUNDAMENTAL CHANGE IN ATTITUDES IS NEEDED

The current academic atmosphere and general mindset of the student body in KMC sees
most students having a tendency of falling into a negative frame of mind by blaming the
perceived deficiencies and shortcomings of the system of education they are in for all
their academic problems. While the system of medical education does require extensive
reform – as long as the current system is in place, it presents a challenge that must be
overcome. Medical students must progress and develop into good doctors. Therefore,
rather than viewing the problems they have in attaining this goal as insurmountable
obstacles, they should be viewed as opportunities to be learnt from, striven against and
eventually overcome.

Besides the pervasive fatalistic and cynical attitude many medical students in KMC seem
to have, there is at present, no genuine peer support given to highly driven, overachieving
students. Any student who gets further than the rest of the pack is not honestly viewed
with critical respect for his efforts and talent, but more often than not, excuses are made
behind his back to brush away or explain such success. In the present environment, an
overachiever never really feels accepted by his peers. For the most part, the majority of
those who see others going ahead of them don’t feel genuinely happy for their success,
but harbor any one of a range of negative feelings.

The alternative is to support, encourage and most importantly, learn from the few who
have what it takes to aim higher and reach their targets. In an atmosphere where the
genuinely interested student is not afraid to show his interest in public, the collective
mindset of the group will evolve to become more perceptive and open to positive change.

With present attitudes prevailing, there is a resultant inertia that must be overcome to get
the student body to listen to the voices calling for positive change. With present attitudes,
such voices are regarded with disinterest at best, or hostile suspicion at worst. The ones
who suffer ultimately are the majority who failed to establish an atmosphere where
academic excellence stands a fighting chance to thrive.

Besides this problem, the general student body lacks the sense of professionalism and
sobriety expected of future doctors. Almost everything relating to academics is taken too
lightly, with the prime motivating factor behind academic effort being passing the final
exam in the end. A walk through the college campus does not impress an observer with
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the notion that the college harbors a sober, serious and professional student body. The
student body in general needs to shake itself up somewhat and approach its chosen
profession with a bit more respect that it is currently afforded.

Perhaps the root of these problems lie, ironically, in the value this profession is given by
our own society. Currently, when most medical students enter their first year, they are too
enthralled in their first few months to do much else than enjoy wearing their white overalls
and act as if they have already become doctors. The respect and prestige they get from
their family and friends for having succeeded in crossing the hard road into medical
college clouds their judgment and prevents them from making a realistic assessment of
their progress in the early days of medical college. Most of them believe that the hard part
is over and that since practically everyone who enters medical college leaves it as a
doctor, it will only be a matter of time before they graduate as doctors themselves. As a
result, the effort put into their professional development becomes far less sincere and
industrious than the efforts they made in trying to get into medical college in the first
place.

There is a second possible reason for the general decline in the student’s academic
performance and attitude when they enter medical college: For the most part, medical
students will have been guided into choosing medicine as a career early in their lives by
their parents - so the decision was never entirely the medical students’ to start with.
When they finally enter medical college, they are so used to others making their career
decisions for them, that they become incapable of thinking for themselves and deciding
what to do after graduation. The notion that a career plan after MBBS must be carefully
planned or at least intended, does not enter their minds because they have never made
such important decisions before. As the notion of what to do after MBBS never enters
their minds, they end up being either very poorly prepared for a post-MBBS career plan,
or they simply follow the herd and do what everyone else is doing. There is, as a result,
no independent thinking going into the post-MBBS career options even late into a
student’s life. The majority, unfortunately, only start thinking of such things after the house
job when the medical college system is finally over. Once outside the system, most
doctors start thinking about what to do for the very first time. Such lack of focus and vision
has the potential to create hurdles in the doctor’s efforts to maximize his success in the
option he eventually chooses.

BE PROACTIVE AND DO YOUR OWN RESEARCH

Don’t rely on anyone else to tell you everything you need to know about a career option –
be it about which books to study or when and how to apply. Do you own research into the
different options. This manual can act as a spring board by giving you basic information
on the different systems - but this manual should not be your first and last source of
information.

The internet has made it possible for a person who has never been through a system to
become thoroughly familiar with it. Everything you’ll ever need to know is on the net. Its
only a matter of knowing how to look for it and being persistent in your search for the
answers to the questions you have.

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To this purpose, besides official and non-official websites regarding the different post-
graduate systems of medical training, you can also email people in the different systems
with your questions and requests for advice.

The best source of information and guidance on any component/issue of any system is
the collective body of seniors who have gone through that system. In researching the
different systems for this manual, I personally met and emailed about 40 doctors. I was
pleasantly surprised to discover that overwhelmingly, these seniors were more than
happy to help me. I concluded that doctors as a collectivity must be more humane and
helpful than most other professional groups. Whatever the reason, you should be
confident that in your quest to seek guidance from seniors, they will most likely be more
than happy to help you – even if you are a total stranger to them. Always be polite when
asking for their help and thank them when they give it. It is fortunate that the senior
doctors/students community is, by and large, extremely helpful to juniors. This fact should
be taken advantage of and you should as a result never hesitate to approach a senior,
either personally or via email for help.

PLAN EARLY AND FOCUS

If you have decided while still a student that you will pursue an FCPS degree after MBBS,
then the clinical rotations during your final and fourth year will provide an opportunity to
cultivate contacts with senior professors who can later help you ensure a house job with
them. Similarly, if you plan to pursue the UK option, you could start building up your CV
accordingly to improve your chances at succeeding in that pathway. If you decide early
on to take the USMLE route, then you could orient yourself early on to the USMLE exams
by correlating the USMLE review books with your regular MBBS course. Therefore,
planning and focusing early on a career option, while not essential, will maximize your
chances for success in that career pathway later on.

If you’re unsure what you’ll eventually do, being familiar with the different systems will at
least let you know what is on offer after the MBBS degree is attained. In such
circumstances, you could use your student years in such an academically productive way
that all options will be open to you when the time comes for you to walk down one path.

It is important however, not to think too much about the future and the problems and
challenges it holds. Worrying too much about potential visa problems in the US option,
job opportunities in the UK option, or low pay in the Pakistani option to the extent that it
causes despair is obviously counterproductive. While a realistic idea of the obstacles that
lie ahead should be borne in mind early on, these potential obstacles should not become
a source of ceaseless worry. You should do everything you can to manage these
problems when they arise and not worry about them before their time has come. It often
happens that a problem that seemed almost insurmountable resolves itself quite easily
when its time comes.

FACING LONG PERIODS OF STUDYING

There is no doubt that staying focused for month after month in studies is extremely
difficult. No one finds it easy, so don’t be disheartened if you don’t. The mental stamina
required to study hard for a long period of time is an acquired skill that only comes with

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persistent effort. Everyone has their own particular problems in trying to achieve good
study habits, and only loads of patience and persistence with careful attention to your
state of mind will help resolve your own study problems. Some people find they study
better at home, others study better in libraries. Some study better alone, others with
partners. Some require constant motivating influences, others don’t. Some need more
time to study the subject-matter, others need less time. Some get tense easily, other are
too relaxed.

Your own peculiar strengths and weaknesses will be apparent only after persistent,
regular efforts to develop good study habits. You need to know yourself very well and
determine what works best for you so when the time comes to start studying for the
career-making exams, you don’t waste time trying to discover your optimum study
environment, timings and pace.

DEALING WITH PERSONAL PROBLEMS

Only those who are very lucky will pass through medical college with absolutely no
personal problems to deal with. Such problems, when serious, can pose a real threat to
your academic progress. As you tend to be more sensitive to emotional stress when
you’re studying, it’s important that you find a way to either solve your personal problems
or find a way to cope with them.

To this end, its very important to have close friends you can confide in and seek comfort
with. The psychological support that comes with sharing a problem is immense. If the
person you confide in is senior to you, he or she may also help you find a way to resolve
the problem, or at least help you to cope with its presence. Whatever the case may be, it
is essential to have your mind cleared of any other pressing thoughts once its time to
study.

The distracting problem may not be related to your personal life, but your own sense of
self-doubt or depression at your apparent lack of progress in studies. In such
circumstances, talking with a senior who has been through the stage you are currently
having difficulty in, will be very helpful. Hearing other people’s experiences in the same
set of circumstances gives you a great sense of perspective. If for example, you are
having a particularly difficult time going through a certain subject or topic, you may be
tempted to feel disheartened because of it. Such negative feelings can be offset however
if a senior assures you that the particular topic is complicated in itself and that the
difficulty you are currently experiencing is only to be expected.

AND FINALLY…
Never lose hope. It’s easy to despair and feel that your problems and the obstacles
ahead are insurmountable. Remain realistically optimistic at all times. It won’t be easy,
especially during long months of continuous studying, when the tired mind tends to drift
towards a depressive state. Remember at all times that even the most highly
accomplished doctors had their moments of self-doubt. To illustrate –of the seven seniors
I have known who scored 99 in their Step 1 USMLE (probably the single most difficult
examination accomplishment of all), not a single one ever believed he or she was good

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enough to earn that score when they were giving the exam. They all went into the exam
wishing they had more time or stamina to study further. No one goes through any of the
post-graduate systems full of confidence day in and day out. You moments of self-doubt
will most definitely come, as they have for all others. It is important to expect such
moments and make the mental struggle to overcome them.

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 ABOUT STUDENTS' LEARNING FORUM

The beginning of 21st century saw the advent of a completely novel idea in Khyber
Medical College. Known as the “Students' Learning Forum”, a student organization
founded in 2003, started working as a wing of Department of Medical Education (KMC).
To start with, it’s main goal is to provide medical students with an organized, authentic,
timely guidance resource source, and to help them solve their academic problems and
thus help them move forward in this highly competitive field. Now popularly called the
“SLF”, this body has been working day and night through the past couple of years to
evolve as a highly professional organization, with a strong infrastructure that was
designed with sustainability in mind. SLF has in this short time reached a maturity of
thought that reflects clearly in its activities. Only a brief overview is provided here.

Career guidance is one of the main work areas of SLF, as is evident from this very
manual. SLF regularly organizes seminars on local and foreign exams for students and
young doctors. These seminars are delivered by those graduates who have recently
passed through the respective exam and therefore help keep students up to date.

Guidance lectures on academic problems of the undergraduate classes are delivered by

the more competent senior students and recent graduates. Topics range from book
selection, study techniques to time management and stress management.

To identify and quantify the academic problems in KMC, a professional approach has
been adopted by SLF. In 2004, a questionnaire based academic survey was conducted
amongst the students with this aim in mind. After collection, the data is being coded into
computer software for statistical analysis, following which a series of Student-Teacher
discussions will be held with specific objectives for each. Rational, scientific solutions are
thus expected to be achieved as an end result.

Perhaps the most daunting task SLF has embarked upon is the introduction of the newer
learning techniques like Problem Based Learning, to both students and the faculty. This is
being done through organizing workshops in collaboration with experts from Aga Khan
University (Pakistan) and Dalhousie University (Canada). Although seemingly difficult to
accomplish at present, the project is expected to continue through the coming years with
eventual implementation of these new systems.

To inculcate the skills of effective usage of internet and computer facilities amongst
students and to promote interaction, the SLF developed an internet based forum for
medical students of KMC by the name of “KMCOnline”, which now has above 600
members. KMCOnline is accessible at http://groups.msn.com/KMCOnline.

As part of its objectives, SLF is publishing an medical magazine on the internet by the
name of “KhyberZine”. It aims to promote scientific writing and research mindedness
amongst the students, and includes items such as interesting cases, research articles,
medical news, reviews of useful websites and books and the like. SLF plans to convert
this magazine into a proper medical journal in due course of time.

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SLF recognizes that a medical student should acquire a variety of skills, and develop a
well rounded personality expected of a modern doctor, apart from academics. In this
spirit, SLF although not directly involved, does promote all such healthy activities. The
introduction of International Federation of Medical Students Associations to KMC by
the SLF has indeed opened up a new world of opportunities for our medical students to
explore their hidden potentials and polish them. Through IFMSA, our students are now
taking up research and developmental projects in the fields of Public Health,
Reproductive Health, Refugees & Peace, and Student Exchanges. These projects vary
from local to national to international level and their scope will probably astonish most of
our previous graduates.

With God’s will, and sincere efforts of the students and faculty, there is no reason why all
these endeavors should not bear fruit. We hope for the best.

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