Dr Deji Ayonrinde, consultant psychiatrist, reflects on the experiences he’s heard from many international medical graduates (IMGs) he’s worked with and mentored. Dr Ayonrinde qualified as a doctor in Nigeria and has worked in the UK for more than 20 years.
He is the Vice Chair of the Professional and Linguistic Assessments Board Part 1 panel, which is responsible for overseeing and developing the knowledge exam for international doctors wanting to practise in the UK.
So, you have finally decided you would like to practise medicine in the UK. This may have been a very simple and straightforward decision, or a long-drawn, painful and convoluted one.
We health professionals may migrate for many reasons – postgraduate study, money, love or a place of refuge away from conflict. Different circumstances and preferences may affect where one chooses to go.
But whatever the circumstance, the decision has finally been made – the United Kingdom it shall be.
Our pre-migration circumstances are bound to be different. Can you afford to travel? What of the PLAB exam fees and the time required to study? Do you travel alone? Where will you stay when you arrive?
It is quite amazing how internationally diverse the clinical teams we train and work in are.
Many migration journeys start this way, open-ended with thoughts of getting a postgraduate education and returning home one day… the accidental long-term migrant.
You start a family, buy a house, and 25 years later you’re proudly attending your child’s graduation ceremony and wondering ‘where have all the years gone?’ Surely it was only a six-year UK plan.
It is quite amazing how internationally diverse the clinical teams we train and work in are. While referred to as international clinical staff, the cultural diversity within each team is unique. Over time you realise migration within the UK, and across Europe, may also be complex, and you observe regional differences in groups you originally thought were all the same.
The PLAB exam is a multi-part professional hurdle that most international medical graduates (IMGs) have to scale to work as a doctor in the UK. Decisions have to be made about how best to prepare. Do you study alone, with a group of fellow first-timers, or with some PLAB veterans, who will have failed the exam at least once already?
How do you revise? You can use material you find on the internet, but there’s a risk that it’s old, out of context and may have the wrong answers. Or you can study books … but how many books and in what specialties?
Do you try to work and study at the same time? And how do you pay the exam fees, from the little money you have left after travel, living and other expenses?
Regardless of when and where you arrive from into the UK, you may find yourself less able to sustain your previous social status for a while. Consider life without a car, and a home without domestic help. Renting property can be a major conundrum – do you save money by renting a small apartment in a less desirable neighbourhood, in a land where postcodes equate to social status, or do you live beyond your means in a detached house in leafy suburbia?
At times you may feel very different and lonely; however the shared professional values should significantly exceed your differences.
Your dreams of getting on the property ladder fuel aspirations to work 22 hours a day and cram your studies into just 30 minutes a week. You are told you can earn a lot more working as a locum, but no one tells you the impact so much work has on your personal and professional lives.
Furthermore, there may be a relentless expectation for you to remit money home or buy luxury gifts given the newly perceived status as a ‘British’ doctor. Unknown to friends and family in the country of origin, it may take a little longer to repay the loans, and the rent and bills drain the salary. A proportion of income may also be spent on keeping in touch, with costly international calls home.
And if you arrive first, your spouse or partner may have expectations of joining you… “Please don’t forget me!”
What a proud moment for you. The PLAB Part 2 results are out and you’ve passed. You can now apply for registration with a licence to practise in the UK. But life goes on around you, and just when you’ve got your wardrobe sorted winter arrives… it is so cold! The shoes don’t work, the jacket doesn’t work, gloves are awkward and the heating bills go up.
Freezing cold at a bus stop or train platform, you hope people don’t notice you’re wearing five layers of clothes. Nostalgic memories of sunnier climes generate little warmth and melt no snow. ‘What am I doing here?’ Someone at work asks if you miss ‘home’, ‘is there winter in your country?’
Things are not as easy as you thought. Unknown to many, you are now working four grades lower than before arriving in the UK.
Things are not as easy as you thought. Unknown to many, you are now working four grades lower than before arriving in the UK. It hurts when a colleague 10 years younger says you are a ‘quick learner’. It hurts when you’re accused of being rude for asking a nurse to make you a cup of tea.
How can it be that when you try to assert a point in meetings that you are accused of having a ‘threatening and aggressive manner’? It hurts to hear people say you ‘overdress’ at work, dressing smarter than your consultant. It hurts when some people say they struggle with your accent, yet they tell you about their exotic holidays to your country.
Status changes and cultural assimilation
How could I have gone through so much social decline from the doctor to a junior doctor? You strategise on how to regain status – a diploma, MSc and a PhD will surely do, or will they? These courses cost money and time, and so does supporting a family, risk versus benefit comes to play. An unhappy spouse is bad for your relationship and mental wellbeing, an unemployed unhappy spouse worse, and an unemployed lonely and unhappy spouse, with a young child or children, worse still.
The BBC Radio 4 programme Inside the Ethics Committee has a collection of excellent podcasts that discuss and debate professional and ethical themes such as end of life care, information sharing, medical issues across faith groups, advance directives, suicide to mention a few.
Professionalism issues may present cultural challenges and emotional turmoil.
Professionalism issues may present cultural challenges and emotional turmoil. Do you prescribe contraception to a 15 year old? A senior colleague has been drinking at work… a woman asking for information regarding her husband… issues which go against your strong moral code -what do you do
Other conundrums may present such as misplacing clinical records… your relatives ask for a prescription… patients young enough to be your child… or exaggeration of achievements. At times you may feel very different and lonely; however the shared professional values should significantly exceed your differences.
The new PLAB exam is trying to help IMGs minimise this risk by knowledge promotion and testing in exams.
While the hustle of medical practice in some parts of the world may not identify or act on these issues, the General Medical Council has a high level of expectation regarding professionalism. What counts as “survival” in one country may lead to considerable shame and embarrassment in the UK. The new PLAB exam is trying to help IMGs minimise this risk by knowledge promotion and testing in exams.
You are determined to do well in the UK. Adjustments have been made to your accent and old friends tease you for sounding so ‘British’. No more calling seniors ‘sir’, no more subtle bows. No more power suits, tweed coats with padded elbows for now.
Eye contact remains a problem though. How does one look senior colleagues in the eye? A friend suggests looking at their nose instead… they won’t notice. It hurt when you were accused of being ‘shifty and dodgy’ because your handshake was not firm enough. And it’s difficult being called by your first name, and calling others by theirs.
You have enough money to eat out, and yet question why your plates have not been cleared away… no one ever mentioned about cutlery positions! And why three forks and three knives?
People ask which football team you support, but how do you choose one? You prefer cricket anyway. Colleagues talk about the theatre, concerts and opera, so you see it as a good time to go to the toilet.
As the months and years pass by, you develop a broad and diverse social network. Friends from work and friends with shared cultural backgrounds.
‘Will I ever become British?’ After all the years I still have to spell my name, and then people ask if they can call me another ‘easier’ name instead, like a letter of the alphabet.
But you are quite proud of your new skills, being able to pray in your head without moving your lips at work. You have also learnt to talk about the weather, and that it is not enough to describe it as sunny but a ‘gorgeous and amazing sunny day’. You are also better prepared for questions about what you did at the weekend.
Homesickness still isn’t easy. You really miss family, friends, smells and tastes. Travel is expensive and the time away so short. Going ‘home’ is exhausting and no vacation but, hold on, where is home? Amazing how much one has come to appreciate the simple things in life as well.
As the Yoruba proverb goes, Onisuru ni o nfun wara kinihun – it takes great patience and resilience to successfully milk a lioness. Don’t give up!
As the months and years pass by, you develop a broad and diverse social network. Friends from work and friends with shared cultural backgrounds. You feel comfortable and integrated with your clinical team. You adjust to the different accents in your home – the British-sounding children and mixed-accent parents.
You see different stages of yourself in the new international medical graduates and smile inside. None of the past experience should go to waste, so you decide to mentor a few. Amazing how much there is to learn outside medicine. You feel proud to be a British doctor.
As the Yoruba proverb goes, Onisuru ni o nfun wara kinihun – it takes great patience and resilience to successfully milk a lioness.
Don’t give up!
The GMC has recently launched a new version of the Professional and Linguistic Assessments Board (PLAB) test. The test has been updated to make it more rigorous and more reflective of real-life practice.
The GMC also offers a free half-day learning session – Welcome to UK practice – to help doctors new to practice, or new to the country, to understand the ethical issues that will affect them and their patients on a day to day basis.
Dr Deji Ayonrinde is a consultant psychiatrist at South London and Maudsley NHS Foundation Trust. He is also an Honorary Clinical Senior Lecturer at the Institute of Psychiatry, Psychology and Neuroscience, King’s College London. He has an MBA from Imperial College with an interest in multicultural and multinational teams.
Kim Tolley explains how our free workshop can support doctors who are new to practising medicine in the UK
The GMC’s Richard Hankins answers your questions about recent changes to the PLAB test for international medical graduates