Supporting Overseas Doctors

Authors: Hamid Zafar, Ferdinand Ohanusi and Charlotte Davies (With personal stories from overseas registrars) / Editor: Liz Herrievan /  Codes: CC24, SLO12, SLO7, SLO8, SLO9 / Published: 06/04/2021

There are many components of looking after overseas doctors. Many of them are intuitive and seem common sense, but our experience suggests the basics are often done poorly. We define an overseas doctors as a doctor who has trained, and probably worked, abroad who is embarking on a new healthcare career in the NHS. There are several different types of overseas doctors, and we’ll explore these in more detail later.  Whether getting pastoral care elements right leads to a  reduction in differential attainment or not is difficult to say

 

We know many of you reading this may not have any direct management opportunity for new overseas doctors, but much of what we’ve suggested and found makes huge differences and do not need to be introduced at a top managerial level. Anyone working in the Emergency Department (clinically or non-clinically), can pronounce names correctly, stand against racism, be friendly, and help with processes.

 

The NHS Employers Code of Practice for international recruitment has a list of  good practice guidelines, including that we should NOT recruit from developing, and some other countries. It’s really difficult not to sometimes as these doctors are really keen to come to the UK, but we must not actively recruit from countries on this list – at the time of writing this includes Nigeria, Pakistan, Philippines and many more. There are lots of guidelines available from NHS employers.
To be able to recruit doctors we recommend they are already on the GMC register with PLAB or MRCEM depending on the grade being recruited to. We do have IELTS/OET exemption but they have to pass an exam conducted by the trust according to GMC guidelines.
The final decision is with the GMC. MRCEM is a basic requirement for a middle grade with mandatory life support courses especially ALS/ATLS already completed. We think the Doctor should have some experience with FAST/eFAST scans, and a middle grade must have 3-5 years of experience in Emergency medicine. We hold our interviews as a two stage process – stage one is through skype and stage 2 is held face to face overseas. We think this gives a chance for both sides to check they are signing up for the right thing – the potential new doctors might realise it’s not quite the job they were looking for.
The contract should be clear at this stage and may include relocation expenses.

MTI Initiative Training

Another route to gaining GMC registration is via the MTI scheme.  The medical training initiative enables doctors from overseas to join the UK NHS workforce for two years, before returning to their home country. The scheme is run by the Royal Colleges and RCEM has details on their website.  The advantage of recruiting through this route is that doctors do not need to provide evidence of their savings, and the disadvantages is that is only for two years!

Supporting Doctors

Right from the very beginning, these doctors will need support. In many hospitals, the overseas nursing teams have been leading the way in supporting nurses, and we can learn from their example. These New doctors need help to find accommodation, get a bank account, know what and where schools exist and reminders to register with a GP. All of these things need supporting paperwork that the local HR team will be able to provide – it’s good to be able to provide this proactively rather than reactively.

 

We’ve amalgamated all our tips into a booklet that all our doctors get given as they arrive. As well as being a reference guide for them, it also does make them feel that we care enough to create the booklet. We’ve included suggestions on what to do in the local area too.

Then our doctors need networking support. They’ve come to the UK and brought their previous cultural identity with them and this needs to shine through. Help them to connect with likeminded people by having overseas gatherings. There’s a beautiful episode of call the midwife where Lucille Anderson, the Caribbean midwife finds the right church for her… which allows her to be a London midwife.

Whilst all Doctors from overseas can generally speak fabulous English, idioms and phrases like ‘spend a penny’ can catch them out – even before you move up North to Yorkshire with the regional accents! Think about what phrases are commonly used where you are.

Introduction to the NHS

The NHS is an institution that’s the envy of many … who don’t work in it!  We think it’s useful to provide a little bit of background to new Doctors about the NHS, and direct everyone to the Kings Fund resources. There’s also a free overview of the NHS course from future learn.
Our really basic “just in time” summary, which we think is important to highlight why we don’t provide some services people think we should is:
NHS England gets given money by the government
They distribute it and send money to the CCG ( Clinical Commissioning Group) often made up of GPs
They commission services, mostly from the hospital
The hospital has to provide the service they are commissioned for.
If the provide a service they are NOT commissioned for, they lose money.
Everyone who gives us money or provides regulation, writes policies and we’re expected to know about them. Many people aren’t used to this potentially overwhelming burden of protocols and policies. I’m sure you can think of more people who write policies, but we’d recommend new doctors know about:

  • Departmental guidelines
  • Hospital guidelines
  • Trust guidelines
  • Local guidelines
  • College (e.g. RCEM) Guidelines
  • NICE guidelines
  • European and international policy
  • DOH policy
  • NHS England Policy
  • GMC guidelines

Other administrative nuances need covering. Payslips need explaining. We had a crack at doing this, and then our medical staffing department took over! Medicsmoney and similar resources are recommended.  We wouldn’t dare to offer pensions advice, but if a doctor doesn’t intend on retiring in the UK, a pension may not be worth contributing to.

The importance of indemnity insurance needs to be explained and encouraged, and the concept of appraisal and revalidation needs to be introduced, to make sure they start the process early, and understand the importance of engaging with portfolios and logs.

We would use this opportunity to signpost the FASSGEM section of RCEM.

Clinical Support

These doctors will all be clinically competent. You wouldn’t have employed them if they weren’t, and generally they’re procedurally better than some already established staff, and know the medicine. There are a few differences between UK and abroad practice that are always worth highlighting early, otherwise they will cause problems, and get your new doctors off to a rocky start:

“Flat” hierarchy

In some cultures, the hierarchy between doctors and other members of the clinical team is a lot more present. The UK involvement with the multidisciplinary team is unique, and those new to the UK might take some getting used to taking advice from non doctor members, and their plans being inputted to by non doctor members. This is commonly exemplified by the elderly patient who has fallen. The doctor says they’re OK, but the Nurse says they’re wobbly on their feet so refers to occupational therapy who says they can’t go home until they’ve had a home assessment. Or maybe, Doris’s son won’t come and pick her up, and she hasn’t got a house key so she needs to stay in hospital as a “social admission”. The role of the family is very different – and we treat our elderly very differently.
All these contribute to patient safety, but it can be difficult for the new UK doctor to get used to this. Related to this, some doctors won’t be used to treating the other members of the team with deference, and allowing their autonomy. The Nurses here will put their argument forward –  and might even suggest it’s quicker for you to remove the cannula yourself rather than find a nurse to do it! They’re a team of equals.

Doctors, particularly the new ones on the block, need signposting to capacity resources – the mental capacity act 2005 and the mental health act are country specific, so they will be unfamiliar with it. Aspects of care relating to this will be different – in England for example, we rarely use physical restraints for agitated patients.

The importance of consent for all procedures, including physical examination needs to be emphasised, as does the chaperone policy.
Confidentiality is different in the UK, and the BMA confidentiality toolkit covers most of it. The phrase “next of kin” has no legal definition or status, and no-one is entitled to have information about anyone, indeed we are encouraged NOT to share information.

The GMC has some worked through ethical scenarios.

Antibiotic prescribing may be different. In the UK we have a lot of anti-microbial stewardship, so don’t give antibiotics for every sore throat, cough and cold. This isn’t the same in every country.
Then of course, some of your doctors will want to become specialists in emergency medicine. They’ll need guidance and support through the process – directing them to this RCEMLearningblog on the CESR will be a good start. We have formally advertised a CESR programme, supporting our trainees with arranged placements and curriculum guidance.

Induction

We cover a lot of these topics in an additional overseas doctors induction. We have a case based approach, covering scenarios we know are likely to be difficult and different. We also focus on, and discuss communication strategies. ‘NHS employers’ has guidelines for overseas induction, and e-lfh did have some specific supporting resources.
The GMC run welcome to UK practice workshops, and some  of our doctors have been able to attend but we are trying to organise the workshop in our trust.

The Racist Patient

It’s always worth reminding people that racism isn’t tolerated in the NHS, and patients cannot demand a white or an English Doctor.  If the trust does not support this position, move to a different trust. There are always complexities eg mental illness, but the bottom line is still the same.

All incidents of racism should be incident reported so that the trust can identify patterns, involve the police if needed, and remind the patient that their behaviour is unacceptable. BAME doctors make up the majority of the UK medical workforce (9,446 in 2019 compared to 6,951 white, 712 unrecorded) with only 53% of doctors identifying as white compared to 86% of the UK population.

Of course, not all racism is obvious, and whilst many will say they do not work in a racist department, keep your eyes open for, and actively reduce micro-aggressions.

I’m not in charge… how can I support our overseas team?

  • Lead from the bottom – be the person who pronounces names correctly, and says racism isn’t right.
  • Talk through your experiences and offer tips before its become a problem – be the chaperone, ask the question.

  • Dust off the GMC booklets that you never read, and pass them on.
  • Reduce and look for micro-aggressions (and racism).
  • Share overseas or IMG resources with IMGs eg. IMG UK podcast and elfh IMG e-learning.
  • Register for the BMA’s IMG newsletter, and encourage IMGs to do the same.
  • Watch the welcome to IMG  video with stories and tips and discussions – youtube link here.
  • Support DAUK’s IMG projects
  • Consider joining NACT, and being part of their LED support group, which discusses a lot of IMG issues. 

Read on for some stories from our overseas doctors.

 

I was interviewed and selected for the post of Emergency Medicine Registrar. After selection I was helped at all levels by trust and consultancy for completing documentation and other necessary processes.  After arrival in the UK, initially I had some difficulties and trouble because of new system of work and different culture but I was very well supported by my consultants, colleagues and trust. With help of them I picked up and settled down very well in the system. Then I also helped in Critical Care Unit during the Covid-19 epidemic. I appeared for interview of Consultant in Intensive Care Medicine within 1st year of my job in UK and got selected for same. Now I am working as Consultant in Intensive Care Medicine and enjoying my work here. The initial support I received from my consultants and trust helped me a lot to settle down smoothly and progress in my career.

 

My experience with the NHS: A truly global opportunity 

During my first few weeks in the NHS, I was almost a rabbit caught in the headlights. Honestly, it was a huge leap from being a doctor in India to moving to the UK. Paralyzing fear, excitement, and bewilderment surmounted by feelings. Though there was immense pride that I had made it to the NHS, the emotion was quite surreal. The anxiousness was never due to the inadequate clinical knowledge but rather the shock of a new system and my crossing with the bests of the world!

Settling in: 

The transition from India to the NHS Greenwich Hospital in London was surprisingly smooth. The initial accommodation was taken care of by my job consultants. BRP was available almost immediately at the post office. Moreover, the hospital staff were quite proactive in supporting the paperwork for the bank account opening. A mandatory occupational blood test was conducted, and an overseas mentor was provided to guide me through the semantics of the hospital and department structure and ensured my well-being, overall.

Induction: 

It is no surprise that compliance is non-negotiable in the medical field. NHS is a palpable example of such an industry best practice. During my first few weeks, I completed my mandatory induction training package, both online and physical. I was given the necessary IT logins, HR orientation packs and NHS access and identity cards. Further, I was also involved in a two-week shadowing with my colleagues and seniors at the hospital on the Emergency ward. My team-mates were extremely helpful, empathetic and were supportive in addressing my naïve questions without any hesitation. I did have an initial setback at the beginning, not knowing fully the processes in place. However, over time I keenly observed the systems and things became clearer as I started putting my hands to work. At the end of my induction, I was mostly awe-struck by the compliance infrastructure of the hospital, building a deep sense of reverence for the system.

Welcome to UK Practice: 

GMC induction was very helpful in introducing me to the latest UK guidelines which was especially tailored for newly registered doctors. The session was comprehensively planned with many real-life simulations. This was very helpful in terms of understanding the local response routes, exigencies, and possible channels of communication. Additionally, GMC Ethical guidance material is a well-documented support literature to keep a medical practitioner abreast with the latest protocols in place, especially at a regional level.

Diverse cohort: 

London is a truly global city, breaking all cultural and hierarchical barriers and stereotypes. Whether one is a cleaner or a consultant, security or a pharmacist, everyone works together. The recognition is solely based on merit and I experienced this first-hand. My colleagues, teammates and support staff are not only professional but hold a deep sense of understanding for each other’s cultures and backgrounds. Moreover, the rotation system allows cultural amalgamations and unifies cohorts to work towards a single goal i.e. serving the patient. An amiable and a professional friendship was quickly established between me and my colleagues based on mutual admiration and respect. I am at loss of words for some of the support staff and nurses who are so dedicated and not wincing once at the sight of getting blood in their hands. This sense of dedication towards work keeps me motivated and driven towards service.

A cultural unanimity: 

The peculiarities between the two cultures is sometimes exciting but mostly dreadful, keeping me at the edge of my seat. For instance, back home, we often assume consent when a patient stretches out his/her hand for an injection. But in the UK, it is still necessary to ask, ‘Are you comfortable with a sharp scratch?’, providing a great emphasis on ‘service and satisfaction’ as opposed to ‘treatment only’. I have been quite proactively making friends outside my circle and with many international colleagues to seek out new knowledge about their culture, food, languages, and possibly learn any new cultural greetings or salutations which may help me in breaking barriers with patients and make them feel comfortable and at ease. The inverse exchange has also taken place where I have provided suggestions to my colleagues from my anecdotal experiences.

The infamous British Weather: 

Well, it is no surprise that the British love to talk about the weather. I come from the Southern part of India, where the summers go up to 42 degree Celsius and 15 degrees on a worst winter morning. Adapting to the zero-degree winter, gloomy weather and the unpredictable rain has been nothing less than a mind-numbing experience. However, I do wait for the summers here and enjoy an occasional barbeque with friends and colleagues. On the flip side, thanks to this mischievous weather, one cannot dismiss the variety of fashion opportunities it provides and guilty pleasure to show off one’s wardrobe.

Personal Training and Development: 

It is a well-known adage that a happy man is a productive worker. NHS takes this seriously and focuses on a holistic development of an employee through Personal Development Plan. For example, A clinical supervisor has been provided to me to guide me through professional development, discuss personal challenges at workplace and support me with my progress both personally and professionally. This program is immaculately planned, tracked, and documented by NHS.

My pursuit continues: 

My journey as a doctor began with a sole purpose of serving the sick and the needy. NHS has bestowed upon me this opportunity to provide my service to the needy and the vulnerable especially during such trying times like the Covid-19. I take this more as a challenge than a merit.   Overall, my 1.5 years journey at NHS has been a transformative experience, with innumerable twists and turns. However, I have only learnt to be more accommodative, tolerant, and positive through the process. With this motive in mind, I take each day as it comes and focus on keeping an open mind to learn something new and contributing every day – one tiny morsel at a time.

Here in this blog , I want to share my experience of my journey to the UK.   The events which were already completed before coming to UK were securing a job, and booking an place to live in UK .

I came in March and after landing in the UK, I realised that the weather was colder than I  expected. It’s good to have a transport booked to take you from the airport to your destination. From the airport I came to the Airbnb which I had already booked. The hosts were an English couple and were very welcoming. The next day was Sunday and I just got  out to see the local shops. The very same day I got the taste of London’s weather where you can get all seasons in a single day. The next day I collected my BRP from local post office . I met the right person in HR who gave me a letter which helped me to open a bank account. The HR also directed me to the occupational health department for routine blood tests. I also met my overseas mentor who guided my through the structure of the department and ensured my well being. Within a few days I got clearance from the occupational health and I was good to join from a pre allotted date.

Working in the UK is very different to what it has been back in the homeland. The transition can be quite daunting and the key is to share doubts and seek guidance and support. Being away from family and friends and adapting in a different work and ethnic culture can be very challenging. I started my shadowing which was for 2 weeks. In your shadowing its very important to observe how the NHS system works and to make the most of this time, its very important to ask a lot of questions to the person you are shadowing and to fellow colleagues. It’s easy to get overwhelmed by the work going in the busy department but everything starts making sense once you get used to it. You can also ask questions to a fellow overseas colleagues who has been working in the system from before. They can guide much better as they have undergone through the same experience and feelings of transition. Anyhow most of the colleagues are always eager to help and explain, including the consultants.

It can take a while to absorb the whole IT structure, as everything is done on computer, but it becomes a second nature simply with time and minimal practice. The clinical stuff is mostly the same but you just need to know the right protocols and pathways, in which the Trust guidance on Intranet comes very handy. I don’t want to less emphasize the fact that you may not be an excellent doctor but you should be a safe doctor. And to do this never a keep a doubt in mind and ask every question, however stupid it may seem.

Communication is the key to an easy transition. You need to gradually make friends with all the colleagues and staff. Introducing yourself when you meet them first time and a simple acknowledgement by greeting them breaks the ice and things become smoother. Culture shock is not unknown and you might feel alienated, but give it a couple of months and you will be a part of the circle as well.

It’s very important to create a social circle and make friends outside of work. You need friends to hangout with to de-stress yourself and enjoy life. Its not difficult to find people and colleagues with same origin or same interests and then build a circle. It’s also important to eat healthily and sleep well and get adequate rest. Speaking of the academic life, you will be allocated a clinical supervisor who will guide you through the various steps needed to build a good portfolio. A lot of emphasis is given on teaching and overall well being. The opportunities for personal development are manifold here and colleagues and consultants are always motivating you to progress.

Apart from these, I also want to share briefly my experience of finding a flat. There are sites like Rightmove and Zoopla which advertise flats and you can choose from various filters as per your requirement. I found a flat through Rightmove, contacted the agency, viewed the flat and eventually signed the contract for a year. The process was very hassle free. The rent and most of the other utilities like water, electricity , broadband can be paid by direct debit.

There are a number of resources available online and on GMC website which provides guidance to overseas doctors.

‘24 Hours in A&E’: An Indian Doctor’s Journey in the NHS 

I was born and brought up in the southern State of India- Karnataka. Renowned for its pleasant weather and multinational IT Companies which attracted its title of Silicon City of India, lessor known fact remains that it also one of the states with highest number of medical colleges and home for one of the biggest hospitals which pioneered Emergency Medicine in India. I happened to be beneficiary of the latter. As I was growing up these two were exactly the career choices for me. An Engineer or a doctor. While I did clear entrance-exams held annually for the admission into both these courses, choosing Medicine was a conscious yet academic decision. Retrospectively, perhaps an early exposure to well established medical centre which I frequently visited with my folks left a lasting impression on me. As I navigated being a medical student and future career option, I happen to realise that I leaned more towards action-oriented aspect of medicine. A turning point arrived when having just finished my medical degree, I signed up for Emergency department of my college. The fast paced work environment, problem solving, people’s management skills at play, the theatrics of uncertainty, no day alike scenario and sheer dedication that is required to pull of a successful day or night got me thrilled and I felt right in place. After internship year I decided to work full-time in A&E at Manipal Hospitals in Bengaluru.

After having worked in the emergency department for 4 years in India, I decided to make a move to the United Kingdom (UK) and work for the National Health Service (NHS). This decision was multifactorial with opportunity to be part of the NHS and career opportunity in the Emergency Medicine in UK being at the forefront. Having worked in a health care setup which varied with region and socio-economic capabilities of patient, I marvelled at the welfare goal and vision of NHS which was truly representative of ‘by the people and for the people’. I was also excited about the excellent academic and training prospects under the Royal college of Emergency Medicine as well.

When I came across the Medical Training Initiative in the UK, I contacted the Royal College directly and obtained details for the application. It is a two-year training initiative for medical professionals from developing countries. I soon applied for the Medical Training Initiative and was setup for an interview with consultants from Queen Elizabeth Hospital, UK. Within a day, I was told, I was selected and given all the necessary documents to apply for the visa and make my move to the UK. The process was smooth and simple so much so that, had I joined as soon as possible, it would have taken one month between application and joining in the UK.  For doctors looking for opportunities to work in the UK, other options are by completing PLAB or Membership examinations of the respective royal colleges like MRCEM or MRCP.

I arrived in the UK on the 28th of May 2019, I had my GMC registration meeting and hospital occupational health meeting in the same week. The medical staffing department was extremely helpful, assisted me with all the documentation required to open a Bank account, National Insurance and followed up on my occupational health results. I joined the ED on the 3rd of June 2019. For the 1st week I shadowed fellow doctors in the emergency department to get used to the department and the system. Although it seemed a lot to take in in a week’s time, I soon figured that when one gets on with the work, it becomes less intimidating. I was given all the necessary IT logins, training for use of the online system and prescribing on the Trust’s user interface. I was encouraged to complete a set of mandatory training to help me face various situations as a healthcare provider in the hospital. This boosted my confidence and equipped me to deal with various situations and problems in day-to-day practise.

I have an educational supervisor and an overseas doctor mentor, who help me get accustomed to the UK, and guide me through my inhibitions and challenges. I soon realized that the system was quite different from what I had experienced in my home country. In the past one year of my work here, what sticks out most for me is that NHS is extremely structured, and protocol driven. This in fact, eases assimilation for a new doctor while also ensuring the level of care provided by him is at par with the standards expected. While strict protocols come with their pros and cons, it allows for uniformity across the whole of NHS and the UK.  NHS inspires a sense of team and healthcare community. Under its holistic fold, NHS fosters a symbiotic relationship between healthcare providers such as nurses, doctors and other staff and its patients. On an everyday basis, I witness an admirable reciprocal reverence among patient population and healthcare professionals in terms of civil responsibility and medical duty that comes with free healthcare made possible via NHS. In addition, the system enables for teamwork across specialities and hospitals within deanery, which ensures that there is someone always to help and share responsibility for management of the patient. Our A&E is a place for solving problems, ranging from clinical to social. This attributes it a character of challenge and satisfaction at the same time.

Unquestionably, work culture in the UK is very vibrant, inclusive, and professional. The hierarchy is not that evident and everyone from top-down share implicit respect for everyone’s contribution in the day’s work which is key to a successful team effort. NHS has zero tolerance to bullying and racism and compensate the healthcare workers well. Apart from this, special care is also taken to commensurate un-social hours and over time.

Over past one-year as part of NHS, I have enjoyed my experience in A&E at Queen Elizabeth Hospital, Woolwich. I believe it has contributed immensely to my growth as a doctor, supervisor, and success in academic pursuits in FRCEM examination. I have been fortunate enough to be a part of the fight against the Pandemic, it has been an experience like never before. It has also prepared me for such events in the future. I fell in love with Emergency Medicine almost a decade ago and as I am about to embark on my training in Emergency Medicine this summer, finally, becoming a consultant in Emergency medicine in NHS is closer to reality than ever before. I am as excited as I am grateful

You can now complete our SBA on this topic. Please log in to access it.


 

Other Links 


1 Comments

  1. Dr Abigail Rebecca Rose Stokes says:

    Great information & ideas on how to be practically supportive to our wonderful IMG colleagues. Thank you.

Leave a Reply