United Kingdom has been a lucrative destination for Indian doctors since the early 1960s. The lure for better financial rewards, better training facilities and improved quality of life (in that order) propels the Indian doctors to overseas destinations with UK being the second most popular country (first is USA). Off late due to a shortage in medical health professional in other developed countries, some other countries have been figuring intermittently on the scene, the good examples being Canada, Australia, New Zealand etc. But these countries lack a well systemasied and publicised route for overseas doctors employement. So currently UK with its PLAB (Professional Linguistics and Assesment Board) exam and USA with USMLE (United State Medical Licensing Exam) exam are most favoured options for medicos in India.
PLAB exam for united kingdom was set up in place in early 1980s to channelise the entry of foreign doctors in NHS and to install a quality control bottleneck for doctors. The initial plab exam was quite high in standards and was one of the most difficult overseas exam to pass. Because of this high level of difficulty doctors started exploring other options esp. USMLE which was comratively a much easier exam to pass rather than to waste years sitting in Eastham, London ( a popular destination for Indian or overseas medicos to converge in LOndon). Some thought that this exam was discriminatory as it was exceptionally tough for overseas graduates.
In fact in 1999 in a GMC review of the PLAB exam, a sample plab test was administered to 50 fully registered UK medical school graduates and only 2 passed. (reference: Doctor, Page 11, 10/6/1999 & BMJ 7199 Volume 318: Saturday 19 June 1999). It was an embarrasing result and GMC was forced to review the whole PLAB examination system. The additional factor for review of the plab exam in 1999-2000 was the growing shortage of doctors in NHS (persumably the previous shortage was in 1970s when Indian doctors were hired in large numbers in NHS).
In may 2000 the new format plab exam was launched. Comparatively it was much easier than the previous format and the examination process was also simplified. Expectedly it proved to a "hit" amongst the Indian doctors and doctors started moving out in droves.
There was a clear geographical pattern in the emigration of Indian doctors in early 2000s with people from South India preferring PLAB exam and people from North India preferring USMLE. The geographical pattern was so marked about that more than 65% of 2000 graduating batch of Banagalore Medical College in working in NHS currently compared to about 3% of 2000 graduating batch of Maulana Azad Medical college, New Delhi ( source: alumni from BMC and meramamc.com respectively, the percentages are approximate figures). The reasons for this geographical distribution being varied - from PLAB being an inexpensive exam, better chances of visa, college trends etc. But during 2003-2004 this geographical pattern is changing shape and doctors from north India are also increasingly migrating to UK via the plab exam.
One of the additional factors in increasing the popularity of the PLAB exam was the clampdown of the USA visas more so after 11/9 incidents. PLAb visa is still more certain than USA visa for doctors.
The striking feature of the current plab exam is the way the exam and the job prospects have been split completely from each other. Unlike USA, there is no formal or centralised system for applying and getting jobs in NHS. The plab exam does not commit about job prospects for the overseas candidates. In recent couple of years getting a suitable training post in NHS is becoming increasingly difficult for overseas graduates. Ironically, instead of reducing the number of plab applicants, GMC has increased plab test places by almost 500% in PLAB Part 2 test and introduced PLAB Part 1 test in new countries and new locations in existing countries (e.g. PLAB centers were opened in Bangalore and hyderabad in 2003 in addition to existing four metropolitan centers - Delhi, Calcutta, Chennai, Mumbai in India).
In the early 2000s when the plab format was drastically changed, migrating indian doctors were surprised by the shortage of doctors in NHS. In many cases (especially in streams like psychiatry), e.g for five adverstised posts only two doctors applied and hence got the job. This appeared to be a panacea for the overseas ambitions of Indian doctors and when this information reached back to India, a mass exodus was generated. Although the needs of NHS is limited to around 5000 overseas doctors a year. Moreover UK itself also trains about 6500 doctors a year. The mad rush for plab which was generated in 2003 led to overflow of the post plab system and Interviews with 60 shortlings for two places became a commonplace in NHS trusts.
There are two steps for any doctors who wish to move to UK. First: PLAB Exam; SEcond: Finding a job.
Regarding the PLAB exam, there is a well placed system put in place by GMC. GMC is the professional body of UK (equivalent to Indian Medical Counil) and is responsible for conducting the plab exam which includes two steps - Part 1 written paper and Part 2 clinical paper. GMC conducts plab part 1 exam in several countries (including UK itself) with largest number of centers in India (6 centers). PLAB part 2 exam can be taken only in UK. The last radical change in the PLAB test procedure was in May 2000 when the exam process was simplified and the difficulty level of the exam was reduced (as covered above). Since then GMC has been continually modifying the elements in the exam ( more so in last couple of years).
Some recent changes in PLAB exam were:
1. Introduction of more plab part 1 centers in association with british council in the countries countries with existing plab part 1 centers. This is to increase the number of local doctors who can undertake plab part 1 exam. We assume that this is based on geographic trends as the new centers were introdued in areas with more numbers of plab takers e.g bangalore and hyderbad. This has effectively increased the number of plab part 1 places in India by 50%.
2. Introduction of plab part 1 centers in new countries e.g russia. Most probably this has been done to counter the increasing criticism of GMC over the overrepresentation of asian doctors in NHS.
3. Increase in the difficulty level of the plab part 1 exam. Since 2003 plab part 1 covered only the clinical subjects and was based on multiple choice extended matching questions only. Since it was covering only a fraction of MBBS syllabus it was considered to be relatively easier than Indian PG entrances and USMLE exams which cover the complete syllabus. But over this year, GMC has started covering the pre-clinical and para-clinical subjects as well in the plab part 1 exam. The format of the questions is also being changed with the introduction of picture tests and clinical scenario SBA (Select the Best Answer) questions. This is bound to increase the time required to prepare for the plab part 1 exam.
4. Prior to november 2003, PLAB 2 exam was held at various hospitals in all major cities of UK. Its frequency was about two exams a month. In november 2003 GMC opened its purpose built plab 2 examination center in London with a capacity of holding the plab exam almost every day. This has increased the number of plab part 2 places by about 500% ( http://www.rxpgonline.com/article-634--0-0.html ).
5. The plab 2 pass rate has consistently fallen from about 85-90% in 2002 to about 30-40% in 2004. Although there are various conspiracy theories going around regarding this tremendous decrease in pass rate, it is hard to pin point any specific and obvious reasons for it.
So overall the first step in moving to UK has been simplified in procedure and made more difficult to pass through successfully. After passing plab part 2 the doctors becomes eligible to apply for jobs in UK. But there is a catch here regarding the doctor's registration with GMC. After passing plab part 2 the doctor recieves a provisional registration with GMC which can be converted to a limited ( and hence functional) registration only if the doctor can successfully get selected for a job. After a year of working successfully in NHS, the overseas doctor becomes eligible for full registration that is equivalent to the registration of a UK graduate or EEA (europian union countries) doctor's registration. Although this seems to be a logical process theoritically, practically it puts tremendous strain on overseas doctors. A provisional registration means that the doctor has to stay on a tourist visa in UK which is usually extensible for maximum of 18 months (extensible in 6 months periods only). If any one is unsuccessful is getting a job in 18 months then they are left with no other option than to return to their home countries. Moreover from 1 august 2003, immigration department of Home office UK has introduced hefty fees for visa extension (150 punds by post or 250 pounds in person). This has results in additional financial burden on the doctor if he or she doesnt get a job within first six months. Moreover since the visa is a tourist visa, there are no options available for doctors to work anywhere to sustain themselves in UK (usually it is london which is infact one of the costliest cities in world). Some of the overseas doctors might end up working illegaly in asian shops or restaurants to sustain themselves. There is a type of work available to doctors in UK which is commonly called as locum work and is meant to cover a regualr doctors sick or annual leaves by any avaiable doctors willing to work for that duration for a fee. The duration of this work can range from one day to few months and there is plenty of locum work work available in UK. THis might be an attractive and reasonable option for overseas doctors to earn some money while they are hunting for regular jobs, but according to GMC registration rules they are not qualified to undertake even locum jobs on provisional registration. GMC has been reviewing its registration ploicies and there are definite proposals to scrap the limited registration in april 2005. But it is still kot known that how this will favour the overseas unemployed doctors and whther they will be able to undertake locum work immediately after passing plab test after the change in registration rules.
Regarding the second step that is finding a job in UK, there is a definite lack of a systematised approach. NHS consists of several hundred independent trust and each trust advertise for vacancies on an as required basis. This is in stark contrast with US or canada system where there is country wide match system wherein your prefrernce is matched with the needs of the hiriing hospitals. In UK the jobs are advertised in various journals and websites with BMJcareers getting the bulk of the advertisements ( bmjcareers.com). New jobs are advertised every week through out the year with peak in months preceeding february and august. (UK jobs are only available on 6 month contracts with new contracts starting in Feb or August). Since there is no centralised sytem, an average candidate sends about 400-600 application to get few shortlistings for interviews. We at RxPG have got emails from people who have been unsuccessful in getting even one interview call after having sent 1000 applications. SEnding an application is a mammoth task for overseas unemployed doctors as Some trusts have combined their 6 month posts into rotational schemes wherein the doctors is offered a combination of 4 to 8 six month contracts at one go, but these schemes are few and are fierecly competed for.
Applying for a job involves filling up big forms for each job, sending multiple copies of CV along with that and posting it by first class mail service. Since on an average a post plabber sends somewhere from 200-1000 applications before getting the first job, this is an immense financial burden.
Accomodation before getting the job is another problem. Usually indian doctors converge on taditionally popular destination in east london - Eastham. In fact the whole economy of the area thrives on PLAB 2 candidates. Almost every house offers a bed or room to share amongst 4-10 plabbers at rates 40- 120 pounds a week. The living conditions in most of these houses is usually extremely bad and certainly not appropriate for doctors. Moreover most of these paying guest accomodations are in clear violation of the local council rules. There has been mushrooming of plab ppart 2 coaching centers in this area with almost 10-15 coaching institutes thriving on plabbers. The rates for these coaching institutes are quite exorbitant (200-600 pounds for 3 to 15 days) and the quality generally of questionable standards.
Getting a job requires a compulsory refrence of the standards of the doctors by a consultant preferably a UK consultant. This is a peculiar situation as overseas doctors usually do not have any UK experience and so can not get any UK consultant references. The only solution for this is to work without a pay with a consultant in UK so that the consulatant can observe the doctor and later on allow the doctor to mention his name on the candidates CV for the purpose of providing a reference. Usually one has to work for six weeks before the consultant agrees to give the reference. This honorary work period is known as clinical attachment or observership. The concept of clinical attachments was rare in UK before 2001. At that time the hospital considered it a privilege to have an overseas doctor working as a honorary doctor in its premises and did everything to make the doctors comfortable. At that time hopitals were known to provide free accomodation to such doctors for the period of attachment. Now a days it has become a model for earning more money for some hospitals in UK. Most of the hospitals in London are charging 40 to 60 pounds a month for providing clinical attachents. Free accomodation has become a thing of the past. Some trust are even arranging interviews to select suitable candidates for clinical attachments when in the past it used to be an informal process. Before getting the job any candidate now applies for about 100 places to successfully get a clinical attachment. The whole process of getting and completing a clinical attachment takes 3-6 months and that effectivly lead to a delay by these many months for being considered for jobs.
Well, most of the problems in getting the first job is due to the oversaturation of market by overseas doctors. Any bangalore top london flight is invariably packed with plab aspirants. It is not rare to bump into few freashly arrived indian doctors at heathrow arrivals terminal on any day.
Done with inputs from Dr A. Padhi, Dr L. Bangaru, Dr S. Agarwaal, Dr A. Joshi, Dr S. Agarwal, Dr B. Sunil from UK.
Note: This is second in our series of reviews about the PLAB exam. This review has been done exclusively by the inhouse team at RxPG and has covered the current plab exam with respect to its history and current situation.