UK licence to practise comes short of a “UKMLE”

From The Lancet 8 May 2010 Thanks to reestheskin for sending me this as he comments “says it all”.

UK licence to practise comes short of a “UKMLE” by Vladimir Gorelov

On Nov 16, 2009, the UK introduced licensing of doctors1—the US way. However, in the USA, it is not just the spelling, “license”, that is different. To obtain a licence to practise, a doctor must sit the United States Medical Licensing Examination (USMLE). USMLE is a comprehensive three-step test of minimum knowledge and skills that are required for unsupervised medical practice.2 For instance, step 1 consists of questions on basic and clinical sciences, such as the example in the figure from the official USMLE website.3 USMLE ranks candidates into performance percentiles and serves as a national standard, independent of individual medical schools.

In the UK thus far, obtaining a licence to practise (or registration, in accordance with the old terminology that the General Medical Council intends to keep along with the licence1) does not require any formal testing of medical knowledge within a national standard. This fundamental difference from the US system has implications, some of which are not immediately obvious. One implication is that the system of recruiting medical graduates into postgraduate training programmes in the USA uses USMLE ranking to select candidates,2, 4 whereas in the UK, a quantitative mechanism of selection does not exist.

UK Foundation Programmes, the first step in postgraduate medical training, rank candidates by scoring their answers to just five questions on the application form. The questions do not have clinical or basic science content. Out of the maximum score of 100 points, each question scores up to ten points—in total 50 points for five questions. By comparison, a PhD scores six points and a peer-reviewed publication one point (no more than two publications are counted). Academic performance in medical school is also ranked into quartiles and draws a maximum of 40 points. However, those in the lowest performance quartile automatically score 34 points, hence all that top-quartile performance can gain—ie, the difference between best performing and worst performing candidates—is six points.5 When one reads the Foundation Applicant’s Handbook 2010,5 it becomes apparent that the academic performance score is diluted by the score of the questions on the application form. Meanwhile, these questions are of a nature that does not allow true quantitative ranking. Here is an example: “You are one of two foundation doctors on a ward round. The registrar identifies a minor error made by your colleague and makes inappropriate critical comments in front of the patient and the health-care team. Your colleague is visibly distressed. What actions would you take and how would you prioritise these? What actions do you believe your colleague should take in relation to these comments? How might you address a minor error made by a more junior colleague in the future?”5 This question alone is worth a maximum of ten points—more than a PhD or the entire medical school academic performance. In the USA, by contrast, USMLE is under review, and one likely change is a substantial increase in fundamental medical science in the examination programme.2

I discovered the difference between the US and UK systems by chance. A junior colleague, who happens to be a Polish graduate, decided to apply for a surgical residency programme in the USA. She passed USMLE in the 99th percentile, which is outstanding, and received an invitation to interview from five of seven programmes for which she applied, including the Massachusetts General Hospital (Boston, MA, USA). In the UK she works in a district general hospital in a junior non-training position that does not allow any career progression, and no one is aware of her true aptitude.

Recruitment of junior doctors in the USA is run by centralised online systems: Electronic Residency Application Service (ERAS)6 and National Resident Matching Program (NRMP).7 In 2009, 36 000 candidates competed for 25 000 junior doctor positions.7 One of the main factors in the successful matching of applicants to their preferred specialty and programme is USMLE step 1 and step 2 scores4, 8—a remarkably standardised and transparent mechanism of selection that results from the fact that USMLE is a licensing condition and is, therefore, required from all applicants. With the use of ERAS and NRMP, US hospitals, in addition to recruitment nationally, attract candidates from overseas, and US graduates are in open competition with doctors from the rest of the world. Both the USA and the UK have a high proportion of international medical graduates in the workforce, 25% and 28%, respectively.9 In the UK, overseas doctors take the preregistration Professional and Linguistic Assessments Board (PLAB) test, but it is designed specifically for them and is not required from UK graduates. Hence, PLAB does not allow direct comparison of knowledge and clinical skills of all applicants, independent of their medical school or even country of graduation, in the way that the USMLE does in the USA.

Thus the UK system, despite the introduction of licensing, still has a long way to go before reaching the power and transparency of its US counterpart in facilitating competitive recruitment of medical graduates. There is now a case for the UK licence to practise to be followed by a UKMLE—the United Kingdom Medical Licensing Examination.


1 General Medical Council. More than 218,000 doctors now have a licence to practise. (accessed Nov 22, 2009).
2 Scoles PV. Comprehensive review of the USMLE. Adv Physiol Educ 2008; 32: 109-110. CrossRef | PubMed
3 USMLE. 2010 Step 1 content description and general information. (accessed Nov 23, 2009).
4 Green M, Jones P, Thomas JX. Selection criteria for residency: results of a national program directors survey. Acad Med 2009; 84: 362-367. CrossRef | PubMed
5 UK Foundation Programme Office. 2010 Foundation applicant’s handbook. (accessed Nov 23, 2009).
6 Association of American Medical Colleges. Electronic Residency Application Service: about ERAS. (accessed Nov 23, 2009).
7 National Resident Matching Program. About the NRMP. (accessed Nov 23, 2009).
8 National Resident Matching Program and Association of American Medical Colleges. Charting outcomes in the match. (accessed Nov 23, 2009).
9 Mullan F. The metrics of the physician brain drain. N Engl J Med 2005; 353: 1810-1818. CrossRef | PubMed

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