International Medical Graduates in the UK (1 Feb 2023)

SPEAKER_02 0:00

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SPEAKER_04 0:32

Hello and welcome to our next episode of Clinical Conversations. My name is Anda Valarga, and I'm currently a trainee and members committee member at the Royal College of Physicians Edinburgh. We're delighted to welcome you to this new episode of Clinical Conversations. Today we have great guests. We've got international medical trainees, got massive experience working and training in the UK, and we're warmly welcoming Dr. Zerfun Tifera, who's currently working in the medicine of the elderly department as a specialty doctor in orthogeriatics at the Royal Infirmary of Edinburgh. And we also have Dr. Francesca Moroni with us, who's a consultant, gastroenterologist at the Aberdeen Royal Infirmary. With me, I also have my co-host today, Dr. Johnny Badgett, and uh ask Dr. Badgett to introduce himself.

SPEAKER_00 1:18

Hi, yeah, everyone. So my name is Johnny Badgett, and I'm a TMC member. And yeah, it's great to have these great guests on the show tonight. And we're all really looking forward to hearing all about the experiences of international medical graduates and their postgraduate training. I don't know if you would like to introduce yourselves.

SPEAKER_01 1:32

Hello, my name is Zeryun Tafara. I go by the name Tafara. I trained in Ethiopia in the Gondor College of Medical Sciences at Isabapa University, and I worked in Ethiopia in different places for about 10 years. I studied public health, sort of international health in the University of Basel at the Swiss Tropical Institute and Tropical and Public Health Institute. Afterwards, I worked with Medicine Sun Frontiers for about five years in various countries in Africa. Then I was living and working with my wife from Edinburgh, and then children came on board, and life became a bit difficult traveling from one country to another country. Then we decided to settle, so that's how I came here.

SPEAKER_00 2:16

That's a great introduction, Dr. Tefara. And I would like to ask Dr. Maroni as well, just to introduce herself.

SPEAKER_03 2:22

My name is Fran. I am a consultant gastroenterologist numberdeen. I'm afraid my introduction will be much less exciting than Tefara. I am a ginger Italian. I moved to Scotland 15 years ago after graduating from medical school in Pavia. I worked a year in Italy and I just did not fit in the system there. And so I took an opportunity to move abroad. And I did all my postgraduate training in the UK. I did a research degree at the University of Edinburgh and then moved back to Aberdeen where I got my consultant post just coming up of 18 months ago. Lovely. Thank you very much both for the introductions.

SPEAKER_04 2:56

So I think to start with, we'd like to explore a bit of the early days, and you already told us a bit about your university degrees. But if you don't mind just telling us about your undergraduate training in your home country. Dr. Moroni, I don't know if you want to start.

SPEAKER_03 3:10

In Italy, at the time I had started university, which was 2000. The medical degree was six years. The first three years were pre-clinical, a lot of theoretical studies, uh, lots of time at lecture theaters, very heavy exams. Difficult to enter medical school, limited places. You had to take an exam to enter. It doesn't work like in the UK. It doesn't really matter what school you went to or what grade you go to school, you just need to pass this entry exam. So I got into a good university, had a good reputation, far away from my home. So I left home, went and lived there. I performed relatively well at university. I wouldn't say that I was classified as the golden girl, but I did well. I was sliding myself. I enjoyed medical school. After the three years of clinical studies, we do two years of clinical studies. Every year you had to attach yourself to a ward beside your routine placement into surgical medicine. You also had to be attached for a year to a supervisor where you would learn some skills to be on the ward. You could be involved in two small research projects of audits. That's when I gained passion into diagnostic medicine and internal medicine. And then I chose already gastroenterologists as a specialty that interested me at the time, probably because I met mentors that were inspiring and I felt welcome in the ward where I was. And when we graduate, at the time in Italy, you had to undertake either a research degree or review degree, and I undertook a research degree in gastroenterology, and my final exam was al Giba, and I graduated as a doctor of meteorology. At the time in Italy, you had to apply for specialty training immediately after completing your uh undergrad. So I knew I wanted to do gastroenterology, but the exams to enter postgraduate training was local, so you had to do it in the university where you were studying because you were had more chances to enter. So it was very limited the choices you had. I graduated in September, the end of the summer session, and unfortunately that here, because of the way that the numbers for gathering training were delivered, there was no an exam until the following summer. So basically, I worked as a clinical fellow in the physiology laboratory in gastroenterology, which is really my special interest in neurogastroenterology motility for about 10 months until the exam came about. But then I realized that it wasn't for me. And then when I applied for jobs in the UK, of course, I had that idea in advance. So I made some preliminary steps forward in terms of English exams and being familiar with the system, you know, coming to UK to see some of the dineries. Uh but we can that's how medical school worked in Italy at the time. Remember that it was 22 years ago when I entered medical school. So maybe things are slightly different now. I know from when you were graduated, you can even enter a degree directly in English. At the time, you can only graduate in Italian. So my undergraduate studies were not in English. I deliberately decided to study some of the textbooks in English because probably already had the idea that I wanted to do something international. But when I went for my interview exams, which were all interviews, none of the exams were written or taken box like I happen in the UK, it is sitting in front of a panel and they will ask a question to answer it. It was all in Italian.

SPEAKER_00 6:32

You've touched on so many things there. Andre, you were gonna ask a question.

SPEAKER_04 6:36

Yeah, I was going to say I'm very interested to learn a bit more about these, even the differences between the medical degrees in Italy and the UK, you know, if these preclinical years. And as you know, in the UK we start, well, later on, we start with patient contact from very early days. So I'm sure you have experience with medical students as well and teaching and how you find that. But perhaps we can explore that in a little bit. And I was wondering if Dr. Tefera wants to tell us a bit about his undergraduate degree as well.

SPEAKER_01 7:04

So my undergraduate study was in a place called Gonder, sort of country, but sort of ancient town, the younger population and conditions mostly dominant on communicable diseases. So my study took six years, three years preclinical, and three years clinical, including in one year internship, the equivalent of foundation doctor here. So the training is very intensive. A lot of fact cramming, especially in the study of basic sciences. And then on the clinical years, very much hands-on practical, a lot of skill building in four major specialities. That was the focus. You come out as a sort of a general physician. So there were only four departments mainly, but there are other more minor departments, but the focus is on internal medicine, obstetrics in gynecology, pediatrics, and surgery. So you will have a rotation in all these departments in preclinical and in clinical years, which means starting from the fourth year. So a lot of, again, as I said, when you come out, you will be expected to practice in all those areas. So you develop a lot of skill, actually, hands-on skill in clinical examination. So there is not really much dependence on technologists in the time I was studying. When I was an internship, that's when the hospital actually got an ultrasound machine, and there was huge excitement. So by and large, it was clinical diagnosis. So you use your skill to do that. So that was the focus, and also sort of to come out when you go into a rural hospital. So you will be the main person, so you should be able to attend complicated deliveries to deliver or to refer, if need be, doing minor surgeries under local anesthesia, maternal and child health, or you will also look after children. So that is very much the focus and also infectious disease, a tropical country. So a lot of malaria. And at a time, actually, when I graduated, actually I graduated in 1993, yeah, decades ago, the HIV pandemic was reaching a peak in Africa. So the same in Ethiopia. So that was the time when we started to see a lot of patients on the ward. So a lot of skill development in management of HIV and AIDS on the ward. Unfortunately, there was not much actually in terms of treatment, actual direct treatment with anti-throw drugs. So very limited. And we used to deal with a lot of complex presentations of HIV. And I worked for about five years after graduating in rural things and also in city hospital. I got very frustrated because of, again, I mean, a lot of days from young people dying from HIV, TB, and Air C, of course. And then I decided I wanted to work in public health. So moved from hospital and started to work in HIV prevention programs. After some time, I got a scholarship in Switzerland granted by the Swiss Agency for International Cooperation and the Canton of Basel. So that allowed me to acquire a master's degree in international health. So I went back to Ethiopia and worked for one year and then moved with Medicine Some Frontier to different places in Africa. So afterwards, my work was actually in prevention, sort of more on program like planning, implementing, proposal writing, report writing, budgeting, staff management, also employment, coaching, training, those types of things, sort of more rather than clinical, of course, clinical guidelines, development and those types of things. So I worked for about five, six years in different places with my wife, whom I met in the journey of working with MSF, which was also working with the MSF. So that's how we met. Then the children come on board, so we continued to work. So when the second one came, then it became it's apparent. Like my job involved traveling within the country and also abroad. So a lot of the time I was away and they were just lonely in a country where they don't have any family, other family members. It was difficult. So 2009, we decided so we need to move. We came actually for the August festival here. So I started to plan to move to the UK system. Then I came actually and spoke to doctors who international medical graduates who started coming to work and what process did it involve. So I explored what does it take. So I need to take exams and what it takes and then to get a job and then start planning. So by April 2010, we moved here. So then the next step is taking the exams, highlights the language exam, then the PLAB one, PLO 2 exams, then I got GMC registration. So the GMC registration was a bit tricky because I worked in different places. So they needed about six certificates of good standing, and getting those sitting here was a bit tough. It took five months. But anyway, in the end, I got registration. Then following that, I took up three, four months observing job in Royal Infirmary, Acute Medical Receiving Urine, and also the wards, and also infectious disease department in the Western general. So I observed for four months. So just the difference to tell about my training, what it prepared me is yes, of course, medicine, the clinical skills, the history taking, physical examination are pretty much similar. And you can, I think those skills remain and you can easily further develop them. I think I was away from clinical practice for five, six years, but then came back, went on courses. I didn't work for one and a half years. So I was just taking courses and just then afterwards, after registration, then the placement, which means then I picked the skills, so the clinical skills again. But the most important thing is the difference, if we come to the difference, is what it didn't prepare me, like my training is like it will not prepare you for cultural differences. I was not prepared. It didn't like the communication skill, there is not really much communication skill training. Yes, there is something called bridging course where you get an intensive clinical examination and history-taking skill, but there is no really dedicated continuous communication skills training. So again, if there is that aspect, I was not prepared enough. Then the other team, except the Hippocrates also, which you will accept on the day of graduation, there is no really dedicated teaching on ethics. So again, those are the type of things. So what I did was actually I took an online course on ethics by the University of Edinburgh online, 10 modules, 10 weeks course, and which was really a very good course. So case studies and those types of things. So it approaches bring me up to speed to what the laws are in the medical ethic principles here. So that was another thing. Clinical audit, I have never heard of clinical audits previously. So I took something again online course on clinical audit from the University of Edinburgh. I attended that. Communication again, I took a face-to-face communication skills course. So these are some of the things I think the soft skills and which I don't know, many places now probably may teach on ethics, but I think these are really important and fundamental when you come to the UK medical practice. So these are some of the things I prepared myself. So shadowing, taking all these courses, and then by January 2012, I got a job with the staff bank.

SPEAKER_04 13:48

Thank you very much for that interesting overview. On to you, Johnny.

SPEAKER_00 13:51

Listen to you both. It sounds like you've had very diverse and different paths in how you've got to where you are now. And it's clear, you know, we all progress through our careers and we have a feeling that you have to follow one path. And obviously, there are many ways to go along your career to get to where we are now. We've touched on some of the challenges that are involved in that. To both of you, what would your advice be to your former selves on how to make the process easier? We talked about language and communication and ethics. Is there anything else that you would have in mind for listeners who are wanting to move and work in the UK?

SPEAKER_03 14:22

Well, Johnny, if you ask me, when people approach me from my country to consider coming through here, I always suggest to start from the scratch. Even if you've worked a couple of years in Italy, do not start as an SHO here. The Italian system does not prepare you to start as an SHO. You have to start as a very junior doctor, you don't know the NHS system, you need a lot of introduction to the service. You can't be the person that is taking decisions. You just need to be someone that can be supervised. Of course, if you start moving here when you're already through your career and you had specialty training, then whatever Tefara was saying about communication skills, that's very important. In the principle of medicine, are the same, wherever you are. If you're a good clinician, you'll be a good clinician in your own country, you'll be a good clinician here. Now, to my former self, I would say two things. Do not pick West of Scotland as your first job because you cannot understand the accent very well. So I was the joke of all the narcissist when I was on for receiving for surgery because I would just say there is a young man coming into urology. What's his name? I said, Well, I can't pronounce it. What's the problem? I said, Oh, I don't know. Then when patients were coming to communicate with me, they were using a lot of slang that I couldn't get. To overcome this problem, I made immediately good friends with my FO1 fellow. Most of them trained in the area. So we shared each other's skills. So I was very good at putting cannulas and taking blood while they could translate for me some of the difficult accents. I recall perfectly my first job as an FO1 and the surgical wards in the Royal Infirmary in Greenock, invocado Royal Infirmary. My at the time registrar now consultant, upper GI surgeon and GRI used to come next to me and translate everything that the consultant was saying in the wardround because I could not get them Scottish mumbling going on. Second thing is you love acronym in UK? Absolutely love it. We do not use acronym in Italy whatsoever. I had no idea what TFTs, LFTs was, but I came prepared. I made myself a little book with all these translations. So I try to keep in my pocket and look through things. Also, measurements, remember, we used US system, you use international systems, so you know we measure glucose in a different way. You know, we measure the milligrams, you know, minimals. That was very different. So I had a conversion of everything with the numbers I learned in medical school, what they meant in Britain. So all these things need to be remembered because you'll be in the war, you'll be looking after patients. And other things I would advise is one big aspect of moving to another country is being able to enjoy the time it is off work. If you do not have that, if you can't enjoy time out of work, work will become even harder because it's already hard, because you're struggling to fit in, to learn a new system. So buddy in with someone, go out, enjoy the culture, try to learn things, watch TV shows. They are people of this country because people will talk about things and you don't have an idea. You can't laugh at a joke when you're at a pub. It's already hard to hear because the music is loud, people are talking, they're mentioning things you never heard before. It makes you feel rather isolated. I was extremely lucky when I started my F41 job here. We were given free accommodations. So we all lived in the hospital accommodation in Bright. So I shared my flat with two lovely girls. I'm still, one of them is still my best friend since I've been here, keeping touch with my other flat mate at the time. They introduced me slowly to the culture, and then I met my husband from now. So I was deeply into Scottish culture by then. But yes, so that's the things that made a difference for me. Having a friend, someone that could translate things for you if the accent was really hard. Make sure you ignore the acronyms because that's everybody talks about acronyms in this country. I remember one of the microbiologists phoned the card when I was working as an FO1 on my second day and said to the narcissist that they needed to speak to me about MRSA. And I said to the narcissist, what MRSA stands for. The Nurses didn't know. I took this phone call from this microbiologist. He clearly understood I had no idea what MRSA is. So he said to me, If his MRSA do this, if an MRSB, don't worry about it. And then I had the time to look through my book and I said, Oh, okay, and nobody says because we don't call with acronyms anything. So yes, these things will happen to the best of us. But yes, if you want to come prepare, these are my advice. Translation book for the acronyms, translation of measurements, a buddy up with a friend that can help you with the language struggles and the skills that they would have learned because we don't do much practical stuff in Italy before we graduate. So you wanted to have someone bodied up that can put talking to the system, start from the beginning and try to get prepared for the culture because that's what's gonna make the life out of work more enjoyable.

SPEAKER_00 19:09

What about you, Dr. Tafana? What would you say?

SPEAKER_01 19:12

So, from my experience, I think how easy they know the question that came, how easy was your transition? I wouldn't say it was easy, but I was planned and I was prepared for what I knew was gonna be a difficult journey, but it paid off in the end. So I think it's very important. Not many international medical graduates probably will be able to come and explore in advance. I had that chance. So if you go through the motions, again, then I think it's also like how much time, how much cost. I personally have abandoned the career that was driving to do a different. So that was a big decision to come back into clinical practice, but that was based on informed decisions. So go into the exams, the registration, I think what I would repeat again is don't rush to start because there is always a rush to go and start. Systems, because the system where you have been working before and it's entirely different. Even within Scotland, I worked in Glasgow and they use totally different systems. There's no track what they use there. So it's very important to know the system. If you are taking up a job in a system that you don't know, then you could be ending up in trouble. So I cannot highlight enough how useful it was for me to just go there and observe. I have the registration. So I went and observed in the acute medical receiving unit in the world. At the end of it, I was actually allowed to see patients and also discharge scripts, and then that means then I'm not paid, but it allowed me to sort of in a relaxed manner to get to use to the system. So even if it's a short, I think it will be useful to observe because you are not from here. I have seen other people graduating from Eastern Europe, they have got the license, then they straight come to work at foundation doctors, they struggle a lot. I have seen foundation doctors like I work in orthopedics, and orthopedics is not a good place to start for an international medical graduate who trained abroad who doesn't have like that observership properly. So observation is very useful. Other things that are very useful are induction. I, by the way, organize induction for the medicine of the elderly, for trainees and also for non-trainees, international medical graduates, and whoever is coming to start whether the local, I give the induction how the department works. And then now I think there is a lot of resources for international medical graduates. I think once you arrive here, there is a WhatsApp group. I think the GMC is now also highly aware about the international medical graduates issues, and they have got virtual and also online materials for IMGs. The Royal College of Physicians also have got some activities. I have attended one meeting. Organized by one of our colleagues, Coran, with the Royal College of Physicians of Edinburgh. The postgraduate education directorate also have got some focus. The NES also have got some actually a dean for international medical graduates. So the profile of international medical graduates is now high. I have never seen it like this. The value international medical graduates is now highly recognized. I attended a JMC meeting earlier this week. Half of the doctors starting in this country, half every year, starting half of them are IMGs. So it is a really large number of doctors starting coming from abroad. So it is being recognized. But at the same time, JMS also recognized like a large number of, I think proportionally high number of international medical graduates are also referred for the medical practitioner tribunal. So the referral is also very high. So they want to improve this situation. So that's what I advise. And one other thing that I would advise is also in relation to risk when you register with a medical defense organization. So in Scotland, there is what's called the medical defense organization of us because MDDUS. And there is also another, actually, there are in the UK, there are about three medical defense organizations. So it is very important you have got indemnity from NHS Rudia. However, for anything that you have committed and stuff for legal representation, it's strongly advised to have the medical organization. Actually, the DMC guidance you must have. So when I started actually observing, I was asked do you have a medical defense? And I was asked to go and have a medical defense. So then I registered with a medical defense. So that's what I would recommend for another medical graduate starting.

SPEAKER_04 23:36

Thanks very much for sharing your experience, but also some very good practical advice. How did you go about that?

SPEAKER_01 23:52

When I moved to the UK, I knew giving up a career. So I'm turning here. The goal was actually making the family happy. So because they were unhappy when we were living in Swaziland. So we moved from Swaziland. So the goal was to live close to the family to avoid any job that involves travel. So the only job I did for two weeks was Glasgow locum. And the next further is one week assisting sort of this endoscopy, sort of this uh keyboard surgery. That's it. So the rest for the last 10 years in NHS Lothian, I worked in a goal was just to train as much as possible so that I can do a hospital job. So to do that, so as I said in the beginning, started the locum, so it was easy. So Staff Bank, I used to work in Ward 104, I worked there for eight months. It used to be called the winter world. So I worked at the locum, the staff bank there. Then within that period, also I got a half-time micro ID foundation to doctor job. So that's four months. Then when I finished that, then I continued to a job and to a foundation to job. So the foundation to job took me to medicine of the elderly and two rotations to libertarian and also all day psych, and the other one was genital general medicine, which was also useful. So my training didn't have any lecture on medicine of the elderly. So I loved medicine of the elderly because it's entirely new for me. And I met really excellent physicians like Nikki College, David Grant, Andrew McIntosh. So they were really brilliant looking at them, and they were my educational supervisors and so on the wall. So I learned a lot of really skills from them, like how they approach patients, how and so then I liked like sort of this holistic comprehensive approach. I didn't know anything called multidisciplinary MDT meeting and those types of things. So then that was an excellent experience from there. Then that was finished. So when that was I have to look at another job in Edinburgh, so I didn't have any plans to go to anywhere else. Then I took up another job, Athletic Hospital. Again, another weak area in my training is rehab medicine. So sort of a GPSD post and a sort of a local role, but involves training. So I stayed there for a year at rehab. So again, that allowed me to rotate into different general and specialist rehab units: neural rehab, amputy rehab, and multiple sclerosis, stroke, and also the orthogeriatric rehab. That's where I met Dr. Gundupe, Sheila Kutz. So then that led because they were used to work there, they told me they had a job in the royal infirmary if you are interested. Then I applied for a clinical field post in 2030 when I finished uh post. So then I said in an interview, then they say, Do you have MRCP? I said, No, I don't have MRCP. So, do you have any plans to be MRCP? Then I said yes. Then I was offered the job to the permanent post. Then my appraisal came up, which is again very important to have an appraisal which is useful in terms of revalidation, something I should have mentioned earlier. So, where my appraisal comes, the same question came up. How where are you with your MRCP? So then I was studying at that time. So, yes, I'm preparing for part one. So I did part one, part two, part three. So I think very supportive environment. Again, the department author keeps very broad. So the biggest department, uh, then I was also working in uh orthopedics. Again, being in the royal infirmary means you have got access to all the departments. So then, although I was not a training, I was able to go and sit in different clinics, just clinic, cardiac clinics, renal clinics, so all that what would be relevant for the PSE exam. So it was easy to undertake the, I mean, for me, I mean, I have gone through the motions of MRCP part one, MRCP part two. So go through courses as usual, and also online sort of materials uh for MRCP. That's the two things I did. So, and then for cases again, online materials and courses. Uh, then the Royal College of Physicians of Edinburgh, jointly with NHS Lothian, organize an excellent course in PESES, three days face-to-face course in the same way the PACS is organized, so which I think is really a brilliant course. Like you will feel like you are fitting for PACS. So I attended that also. Again, the Royal College also organized a PASE evening, again, two or three evenings on PECS lecture again. That was the valuable course. So I think these were all very helpful. Then I completed my MRCP course in 2018. I'm not the conventional person who goes through the training post, but I think still it's doable, it's possible to do the MRCP. As I said, my focus is balancing life around the family and also, yeah. So I live close by four to five K from the Rwandan firmary. I decide to work, I run, I walk at the distance. So that's a really good balance for me. Yeah, as Francesca earlier mentioned, I think life is not only about medicine, I think it's really very important to have life outside of medicine. As a British thing, we have got also allotment. Yeah, we grow potatoes and licks and those types of things. And in the garden, we grow berries, so it's just to balance things so that life is not stressful. This is purely, I mean, especially nowadays, if you are really purely focusing on work, it could be extremely stressful.

SPEAKER_04 28:44

What about you, Dr. Moroni? How is your training path?

SPEAKER_03 28:47

Well, because I started a convention as an FY1, I just follow the routine path of doing MRCP. As I mentioned, I was lucky enough that I choose my specialty very early in my career. So I knew I wanted to be a gastroenterologist. However, I would say the UK training system allows you to experience much more than other training systems may do because in your junior doctoral years, you go around many departments, allow you to see the work environment, what this can offer you, and maybe you change your mind. But for me, MRCP was hard. I mentioned when you asked me about medical school, I said we don't do written exam unless at the time. There was no written exam in my university, it was all interviews, extremely stressful. But that allowed me actually to develop skills that British graduates didn't have. So I was very comfortable and presenting case to my consultants because that's how my exams were. But I was terrible at doing exams with you know multiple choices. So the only multiple choice exam I ever did before coming to UK was my written driving test. That is bad as it was. So I did fail my Marcy P part one. I struggled. I don't think it was about the knowledge, it was about the technicum doing the exam because I realized that as I was overthinking every answer. So I gave myself rules the second time I did my exam, and I was only allowed to change the answer once, even if I then knew it was wrong, because I went and read books about both choices exams. Actually, you're more likely to be right the first time. So I just I gave myself that rule and I passed my MRCP part one. What really helped me in that process is failing. I was a good medical student and I didn't fail exams before. So actually, it helped me through my career fail in the MRCP part one because it's really important, above all, as an international graduate, to accept failing and not because you're not as good as other people. You just come from a different background. So sometimes you just require a little bit more of time, and that's what I needed. Because I started Zephyr1 with a peer group of my similar age, with similar experience, it was good to be do the MRCP together, we studied together. Some of us failed together, so then we had to sit in it again. So I found it stressful by in one way quite bonding and formative for me. And then in my part two, I passed it first time, and I enjoyed Paces. I think I was the only person actually finding the easiest part because I was so used to that type of environment. So that was fine for me. I attended one of the courses just because I'm Italian, you know, don't forget that we speak with our body all the time, and our hands are going everywhere, which was a significant problem when you're in a British environment where everybody's so stiff. So I could not stop moving my hands when I was introduced to the basic exam. So my kind mentor at the time said, I think you need to go and watch someone else's how to do it. But he gave me this advice to hold my stethoscope behind my back with my hands, and I will tell you my knuckles were pure white because I was scratching it so much because I didn't I really want to move my hands. All these little things, you don't think about it because you know, in your culture, this is natural. That's how we speak. But I had to learn these techniques and how to fit in the system. When I compare my MRCP, I've done it all in the right timing, so I was able to apply for specialty training. Now, there is one thing I didn't mention that a part of the exams I had to do several times since I've been in UK is my IELTS exam, which is an exam that proves that I can speak English in an academic way and I can read it and write it. Now, fair enough when I came to the UK before I start my job as a doctor. But the problem was half the way through my training, because it only lasts for two years, I said you have to take it again. But I've been working in the NHS as a trainee doctor for two years, passed my MRCP part one, but still I had to take my English exam again. So that's money that I had to spend for no apparent reasons. Then I came to my application to my specialty training, and I was declining applications because I did not have my updated English exam. However, my colleagues that didn't pass MRCP were allowed to apply. Thank God I had a very nice at the time lead of the TMT program, they advocated for me and I was allowed to apply for my specialty training with the closed that I would take my English exam again before my interview. Now there were no spaces at all in Scotland to complete my English exam, so I took it to London to do it. Anyway, apastic, really, because by then I worked in UK for about four, four and a half years or something, so I could speak good English. But that was a thing to make you aware that there is this extra layer of problems when your undergraduates is not in English. And then I applied for my specialty training, and that year there was only one job in Scotland. At the time, it was on divided by Scotland, England, Northern Ireland, and Wales. So there was only one gastroenterology position in entire Scotland. And I was selected to be one of the three people that got an interview. Everybody else has applied didn't get it. So I feel that it was very rewarding for me. Even if I didn't get a training post that year, I got a lot job that was available in Glasgow, which was fine because that's where I did my foundation and CMT post. But I felt it was very rewarding and a sign that actually this system overall is quite fair and meritocratic because there were a lot of British graduates that applied for the position and they didn't get an interview. So whatever I did and I put in my applications was sufficient to suggest that I would be a good candidate to obtain a job. And then I had to reapply the following here, and then I got my training post, but it was in the Northeast courses had to move. Thank God they never asked me again to do an English exam. But even when they applied for my MD at the University of Edinburgh, I had to say that my degree was in Italian. However, they accepted the fact that I work as a doctor in the UK for so many years and said there's no need for you to do an English exam. You clearly pass all this exam and you're fine. But so the system can be sometimes a bit rigid in that sense, which is a good safety net because you know there is certain rules that everybody has to comply to. But on the other hand, can sometimes be a little bit short-sighted if you're not seen using some common sense that you know I've been here for so many years and been speaking to patients and prescribing medication and doing all that, but no, I need to do another English exam. But it's part of the culture, you know, you have to accept that things are different. And I would I would expect in Italy, in Italy, it's much more used to be at least much more wishy-washy, and that would be fine just because you know someone, which I didn't quite agree with, but nevertheless. And when I was training in my specialty training, then I did my specialty training exam, and that was fine, well hard, very hard, but I faster, so that's okay. So that's me finish my exam, although I still have to discuss my vibe for my MD, but I'll be fine with that.

SPEAKER_00 35:20

So it sounds like there are a lot of challenges just navigating the whole process. Did you know that the language assessments would be part of the process as you continue throughout your career, Fran?

SPEAKER_03 35:30

Well, no, my understanding was I needed to do it to start my process and be in a junior doctor. I knew it was only valid for two years, but I didn't expect I had to repeat it every time they applied for a new position in training because if I was considered good enough to be an FY1 with my English and I demonstrated I performed here for two year past exams, it made no sense to me. They were expecting me to retake my exams every two years because I was in the country and I was practicing medicine. So if yesterday I was good enough to be a doctor on the ward, why am I not tomorrow being good enough to be a doctor on the ward? So that was my conundrum. But nevertheless, I did the exams because I wanted to progress in my career and I had no intention to go back to my own country. So I accepted that. But I was very demoralized when they declined my applications for specialty training, and I was very grateful for someone that actually advocated for me with an NES, you know, an education for Scotland, and say that was ridiculous. But the only way they accepted my application was for me to take another English exam. Alistair was allowed to apply. So there will be things that will sound slightly unfair. But I wouldn't expect and I didn't know Johnny that I had to do my English exam before applying for my F1 job. And one of the things I did in my last year in Italy, I engaged into a course specifically to pass IELTS exam at a British council, which wasn't in the town where I live and was doing my clinical fellow job. So it was in Milan. So every evening after my job, I had to take a train, go to Milan, attend this course. It was three times a week, so it was a big thing to do. But I was well committed then. So I'm not shy of work, I'm not shy on doing these things, you know, if they needed, need to be done. And I think it's right that you have to demonstrate you can speak good English when you come. It's not just me communicating with a colleague of mine, because most of the medical terms that we use come from Latin and Greek. So for me, it's like speaking Italian. Sometimes I don't find difficulties in remembering correct medical terms for parts of the body or diseases because that's my studies and my language comes from Latin. The difficulties is when you have to communicate with a patient or a relative. So if your English proficiency is not good enough, you don't sound professional. Miscommunications is the commonest reason for complaints against medical profession. So you have to have good proficiency of English. So I'm very supportive of that. I think it's right that we need to do exams to show that we can speak good English and read well, understand well, write well, because we write letters to patients and discharge letters is very important communication. So I'm really supportive of this. It's just through the process you would have expected. If yesterday I was good enough, tomorrow after working in the same position, my English will be good enough. You know, we overcome that. And now I'm here in a consultant position. Quite happy with that.

SPEAKER_04 38:10

So it's been a long journey, a lot of dedication, as you said, commitment challenges. But tell us about some of the positive aspects as well along the way and the things you most enjoy in your day-to-day work and this kind of transition experience to working in the NHS.

SPEAKER_03 38:24

Well, for me, this system really fits my personality. I mean, in Italy, the health service is national too, so it's free in some way. But I would say there is even more disparity in terms of access to the medical health care that is in here. So I very much believe that it's a right to every individual to have good medical care. And I think NHS is outstanding in essence. I found the meritocratic, as I said before. There's been several occasions when I found myself very supported throughout the system. In Scotland, specifically, as a trainee, is a very personal experience. People tend to know you. You know, in a small and specialty like gastroenterology, everybody knows you where a trainee, no matter where you are. It's very bonding, good, strong relationships. I like very much the multidisciplinary aspect of the work, as Safara mentioned, as very rewarding being able to work with other specialties. You don't get that in Italy, it's very, very much protective of your own specialty of your own patients. I do strongly feel Italian and I want to retain my heritage. And I think I bring something that other people don't have. I am very straight token, I'm very honest. And one of the things I found that is very strange when I moved to UK is people meet in the corridor and they said, Oh, hi, how are you? And I would stop and tell them how I was. But I realized it's actually not a question. They don't really interest me to know how you are. Let's just say hi. So I know people find this really odd, but I couldn't understand. Why didn't I want it to know? They just asked me how I was. So anyway, but I like that. I'm Italian, so if you ask me how I am, I tell you if I had a bad day. I enjoy work, I enjoy being different from other people at work. I enjoy the relationship with my patients. I also do a very niche start of gastroenterologist. I'm in the nutrition service. There's only like three or four of us in the old Scotland. So, you know, I know that I'm very well known in the country now. I get a pharaoh from out with my service. It's hard work, lots of hours. Many shifts, uh COVID uh, you know, almost killed us all, not just because of the illness, because of the resilience we had to put into the job. I'm very lucky when I go home. I have my little family with me. I am lucky. Money is good, you know, compared to Italy. We earn good money even through training. So I was able to sustain my own life. If I was in Italy at the time and I took a specialty training, then there was no way that I could leave on my own in a house. There was no enough money for that. I feel that there is a good system for like sick leaves or maternity, paternity leave, even parental leave. I didn't even know it was a thing. I just discovered it very lately. And my son is nine years old. I could have had parental leave for years. But, anyways, it is a lot of good things that I would say. I enjoy the cultures. There's many things that I don't understand about British culture, or I don't quite embrace because I'm from a different heritage. But you have to accept where you are is a different place. You know, I became a British citizen in 2019. I had to take an exam to become a British citizen, including culture exams, and some of the things are enjoyable, you know, like to know that is important to Brit to make sure that I know about its standards. Although I never watched a single episode, but I had to learn about it in the book. So, anyway, every day is a discovery of things I don't know. This morning I was playing the world, I guess the words, but I had no idea what it meant. So I had to go and search it to Google Translate. It's good, you know. Every day I learn something new. I become a bit more British, but I keep being Italian. So this, I think, is all makes the NHS or the work environment to have people like me, like Tefara, very special because we bring something that you don't have every day. So I think there is a lot of work that needs to be done to ensure that international graduates are welcomed, well received, and prepared to work here. But also what is important is for the people that are here, they graduate here, and they're from this country to learn from us something, to accept that we're different, to accept sometimes the way we approach things or problems is maybe better. And there is things to be learned from each other's every day. So that's what makes the job very enjoyable.

SPEAKER_00 42:19

And what about you, Dr. Tasara?

SPEAKER_01 42:21

Yes, a lot of positives, I must say. Yeah, passing all the challenges and the difficulties, definitely. I think one of the most important for me is actually living public health, then coming to clinical practice. I find out actually I used to miss clinical practice, and I really actually find out I am much more a clinician than a public health specialist, meaning I think it was great coming back to clinical practice. I think that's where actually my superior skill, or that actually what I enjoy a lot. And then to have that opportunity also to practice in the areas which I actually wanted to do is also another excellent positive privilege, actually. Without I'm I didn't want to train, but I think in the job where I'm doing for self-directed development, and then just to do what I love to do is an excellent positive. Again, as I said, I didn't have any background in geriatric medicine, but I trained myself with the help of all the trainees and supports in the department. Now I have the post as a speciality grade orthogeriatrics geriatrician in the orthopedic department. So that means I can work semi-independently, I can assess patients on my own, and at the same time, I have got the backup if I need the support, if I need to ask somebody, maybe I need support on a patient. So that's again a great positive thing. The system allows, as I say, for development. Like if the department did not mention MRCP, I definitely wouldn't have gone for it. So I don't have any plan at all. Actually, somebody previously before this job asked me, Do you think of MRCP? I said no. So but I was asked on the job and I said, I think there is no way out now, so I have to do it. So The department for this is valued, so then I have to do it. So I went on through it. So which again the department, and then again within the same department. So for teaching or being observed and receiving feedback. So I'm extremely proud, actually, I did the MRCP. So it's really an excellent. So I am extremely confident now, like in terms of my communication with families, with patients, with the staff, concerns, whatever I have. I don't have any difficulty raising in any difficult conversation with even with senior colleagues. So if I don't agree with the decision that has been made on the clinical, I say my view. So that is something skilled that comes through training. So which again, I think I'm very proud of that. Again, there are a lot of opportunities, like uh to teach, for instance. Like there is what's called the clinical education program. So during my appraisal, again, it came like, okay, there is this clinical education program. So if you are interested, you can go in and through. I explored it. And then I went through the motions, level one, level two, level three. So I completed the three levels, which is, I think, if I didn't actually realize actually it's really highly recognized when you complete the level three. So and I teach students in the University of Edinburgh clinical computation skills, and also large group before COVID, I used to teach large groups of students on delirium, dementia, and depression on a topic in the curriculum. And also on the bedside, I teach medical students, I teach foundation doctors within the department. There is a slot for with the orthopedic foundation teaching. So there is MOE slot. So every month I teach subject on that. So again, these are opportunities which really make me happy. And it just worked out well. Like this was my plan, actually. My wife are happy, the children are thriving. So I must say everything is good. So I must say a lot of positives from the work. And another thing is in terms of like I worked abroad. So it was not easy, but I had my previous experience recognized, so which have got impact on how much I paid, how much annual leave I could be getting. So again, the alternative would mean then starting from the bottom. So my previous experience was investigated with references from previous uh employers and stuff, and then that was recognized. So again, that is a happy point. So I think other than that, maybe one last to finish off is like I don't intend to go into training, that's the sort of definite plan, but an opportunity to become a consultant, and I'm gathering evidence through the CISAR route through covering the curriculum of geriatric medicine. So I have still to do a lot of work on that front. However, it is possible to become a consultant. I know that.

SPEAKER_04 46:32

Thank you so much, both of you, for sharing your insights, but also your rich experience of training, working in the NHS and doing exams in the NHS, and also sharing aspects, these cultural aspects and life outside work as well, which is very, very important, as you said. I think this is all going to be very valuable for our listeners, future and prospective and current international medical graduates. And we're very, very grateful for sharing your experience.

SPEAKER_01 46:59

Thank you for inviting us.

SPEAKER_04 47:01

Thank you very much, and I hope that the audience also enjoys this episode. As always, give us feedback, and many thanks again for your time.