“We’re so lucky to have these wonderful trainees,” I would often hear from my fellow GP educators. I would say it too. And indeed, we did feel lucky to have these brilliant, passionate, clever trainees who would breeze through their exams without needing any additional support, intrigue us with their thoughtful reflections and challenge us with their insights. And there was more – they would win prizes, participate in ground-breaking research, and go on to positions of leadership.

And we were lucky that their hospital trusts released them every single week to attend their half day release, termly awaydays and annual two-day residentials, that gave us the room to flex our teaching muscles, designing sessions that were provocative, innovative and unusual. We brought in speakers to focus on the health issues of marginalised patient groups: migrants, domestic abuse survivors, prisoners, the homeless, trans people. We ran book clubs to examine patient and doctor narratives, facilitated discussions on unconscious bias, professionalism, ethical dilemmas. We created games, co-designing a “thesaurus of primary care”, artworks to celebrate our heritage, pantomimes with a political twist, wellbeing activities to promote bonding and support within the group. Our trainees had fun and flourished. And so did we. There was certainly no need to do sessions on how to study or pass their exams when this was a given. Re-sits were simply unheard of.

But was it lucky? It certainly wasn’t luck that afforded the hospital trusts the ability to release the GP trainees for their training; well-staffed with several speciality trainees, it was straightforward for the rota managers to accommodate the timetabling needs of the GP trainees. But more significantly, the trainees had all scored extremely highly in the national recruitment process, allowing them the opportunity to get their first choice of placement. And they had chosen a training scheme that was urban, centrally located in a prestigious, tertiary referral centre. Given the recruitment score is highly predictive for success in all aspects of the MRCGP assessment it wasn’t luck at all that saw them sail through their exams[1].  When it come to the different training schemes, the differential attainment that has dogged the MRCGP for so long[2]^,[3],[4],[5] is baked-in from the word go.

But it wasn’t until I became an educator in an altogether different part of the country that I understood the flipside to this “luck”.  In my current training scheme, the patch is under-doctored and deprived, the trusts are in crisis, only able to release to the trainees from their hospital posts once a month at most, the vast majority of whom are international medical graduates (IMGs). Dr Margaret Ikpoh, Vice Chair for Professional Development for the RCGP, in her expert witness testimony for a recent House of Commons report on the future of general practice described this as the “inverse education law”. She outlined how the high concentrations of IMGs in disadvantaged locations was problematic: “Ultimately what we are doing is putting trainees who are not particularly familiar with the nuances of the NHS into a system that is already under-doctored and stressed and which perhaps does not have the capacity or the premises to provide the training that they need to become partners.”[6]

My current trainees have much lower recruitment scores, unsurprising given their unfamiliarity with the way medicine is practiced in the UK.  This afforded them little choice over their eventual placement. Many have found themselves in strange environments, isolated and lonely, or commuting hours every day. Despite having undergone highly selective processes to obtain their primary medical qualifications, the social, cultural, and organisational context of the NHS baffles them. They are often overwhelmed with the enormity of the task ahead of them, but reluctant to seek help. Recent Ipsos research for NHS England into the experiences of IMGs in GP training confirms this picture[7]. The IMGs they spoke to described a combination of pernicious challenges; difficulties with induction, relocation, transition into the workforce and navigating the visa system, on top of unfamiliar and complex training demands. And there is the expectation they will be successful in the very assessments that the data tells us they will struggle with in just three years.  In the same way, my own research into the views of GP educators echoed concerns about the inequity and structural racism inherent in the design of the system, and several felt that the recruitment scores should be scrapped to allow for more diversity and peer learning within schemes[8]. But sadly, there is currently no suggestion to change this fundamental aspect of recruitment. The inverse education law that sees the “lucky” trainees experiencing innovation, creativity and fun, while those most in need having a different training experience entirely, is stronger than ever.  As one of my research participants, reflecting on the challenges the IMGs faced, put it; “They are set up to fail”.

But I still feel lucky. Lucky to have the most conscientious and indefatigable colleagues, who work tirelessly to understand and meet their trainees’ needs[9]. The IMG trainees I work with have access to sessions on study skills, linguistics, and acculturation into the NHS as well as screening for neurodiversity, bespoke learning needs analyses and coaching.  These initiatives, which match what IMGs have asked for, are being introduced across a number of specialities and undoubtedly make a significant difference to the differential attainment they experience[10]^,[11]. Pass rates have at last started to climb.

And I am beyond lucky to be inspired by equally passionate and brilliant trainees, who despite facing emotional and financial burdens and social and educational hurdles, do NOT fail.  With incredible courage and perseverance, they challenge our preconceptions, overcoming their disappointment, adapting their learning, finding new strategies. The underlying inequity remains – there simply isn’t anything left in the kitty for the extras their more fortunate colleagues in the ivory towers get – but I still feel lucky that the future GP workforce is diverse, determined and so very formidable.

References:

[1] Siriwardena AN, Botan V, Williams N, Emerson K, Kameen F, Pope L, et al. Performance of ethnic minority versus White doctors in the MRCGP assessment 2016–2021: a cross-sectional study. Br J Gen Pract. 2023 Apr;73(729):e284–93.
[2] Esmail A, Roberts C. Academic performance of ethnic minority candidates and discrimination in the MRCGP examinations between 2010 and 2012: analysis of data. BMJ. 2013 Sep 26;347:f5662
[3] Shah R, Ahluwalia S. The challenges of understanding differential attainment in postgraduate medical education. Br J Gen Pract. 2019 Sep;69(686):426–7.
[4] Woolf K. Differential attainment in medical education and training. BMJ. 2020 Feb 11;m339.
[5] Linton S. Taking the difference out of attainment. BMJ. 2020 Feb 12;m438.
[6] Health and Social Care Committee. The future of General Practice. London: House of Commons; 2022 Oct. Report No.: HC 113. Available from: https://committees.parliament.uk/publications/30383/documents/176291/default/
[7] Worlledge G, Weigold E. International Medical Graduate GPs Research: Experiences of training and transitioning into employment. NHS England; 2023 Jan [cited 2023 Aug 17]. Available from: https://www.ipsos.com/en-uk/international-graduates-have-positive-experiences-of-gp-training-face-challenges-domestic-students-do-not
[8] Wedgwood F, Khan N. Reflexivity and inclusion in doctors’ training: a qualitative study of GP educators in the UK. [manuscript submitted for publication]. 2024.
[9] Warwick C. How international medical graduates view their learning needs for UK GP training. Educ Prim Care. 2014 Jan;25(2):84–90.
[10] Lagunes-Cordoba E, Maitra R, Dave S, Matheiken S, Oyebode F, O’Hara J, et al. International medical graduates: how can UK psychiatry do better? BJPsych Bull. 2021 Oct;45(5):299–304.
[11] Hashim A. Educational challenges faced by international medical graduates in the UK. Adv Med Educ Pract. 2017 Jun;Volume 8:441–5.

Author

Dr. Frances Wedgwood, GP, Educator

Dr Frances Wedgwood is a GP, educator, and researcher into education in primary care.

Declaration of interests

I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.