AVOID the UK, Australia and the USA for specializing in medicine

Dr. James Manos (MD)

April 12, 2020

Why should a doctor better AVOID choosing the UK, Australia, or the USA for specializing in medicine?

Image (free to use): A medical professional wearing a surgical mask during a surgical operation to remove a hemangioma (at the California Pacific Medical Center) (February 8, 2007). Uploaded by the user:  Artur Bergman. Source: CPMC Surgery; Wikipedia. Link: https://en.wikipedia.org/wiki/File:CPMC_Surgery_(412142792).jpg

Abstract

Although an Australian, I advise international medical graduates against choosing the UK, Australia, and the USA to specialize in medicine as they do not show they need them! From this advice, specialists are excluded. Regarding the UK, the NHS system is on the verge of collapse, while they currently ask for experienced doctors even for junior posts! In Australia and the USA, foreign graduate doctors who wish to specialize there must take costly exams regardless of graduating from a Western or a developing country! The success rate in Australia is low, while the fees are exorbitant. Doctors should choose other Western countries that really need them, such as Sweden! 

Contents

a) The British National Health Service (NHS) is on the verge of collapse!

b) Why you should NOT choose the UK for specializing in medicine!

c) Why you should NOT choose Australia and the USA for specializing in medicine!

d) Private vs. Public healthcare: Which system is to the benefit of the patient?

e) Is there an optimal Western healthcare system?

a) The British National Health Service (NHS) is nearing collapse!

Overview

In the British National Health Service (NHS), things are predicted to deteriorate, as it is financially unsustainable, and some speak even about its (semi)privatization, as in the USA! In March 2016, junior doctors in the UK went on strike, complaining about pay cuts and exhausting working hours. In many Western countries, problems still show that healthcare systems are not flawless. In the UK, a junior doctor is paid annually only 32,400 dollars! With this meager income, a junior doctor should pay numerous obligations, such as paying nearly 1,000 dollars to rent a small apartment in London. 

The NHS has many problems. The most significant is underfunding. Another significant issue is that many posts, covered mostly by international doctors, are service instead of training. Hence, they are not educational, approved by the Dean, but we have a service type of doctor like an employee of a supermarket! 

It is doubtful whether the NHS in the UK is the best healthcare system. I am not sure if they are even satisfying! The question is, who does the rating? A healthcare system evaluation should be performed by independent international authorities such as the World Health Organization (WHO) rather than local, such as NICE in the UK.

Regarding the NHS in the UK, although its myriads of ‘standards,’ it has many flaws, such as the long waiting lists for surgeries, as well as the fact that most foreign doctors run the system offering service instead of sustaining official (having the educational and Dean’s approval) training. Another significant issue is the recent underfunding of the system, which has worsened after Brexit. Already, the wages and working conditions of junior doctors have caused frustration!

According to Public Health England’s annual health profile, British women have the lowest life expectancy in Europe at birth, at 83 years! The longevity in the UK is ranked 17th out of 28 European Union (EU) nations! Women born in England can expect, on average, to spend 19.3 years, 23 percent of their lives, in poor health! Statistics for men in the UK are slightly better.

The flaws of a Public Healthcare system

There is controversy over the ideal system; some argue it should be public, while others insist it should be private. In the US, contrary to common belief, the Medicare system is a public-private partnership, while the decisions to pay claims are made by private companies! Contrary, in the UK, the NHS is public. Both systems have flaws. Most important is their underfunding. The overpopulation in Britain and the increased demand to treat senior citizens with infirmities have brought the NHS system to its knees. Things in the UK are getting worse. The waiting lists for visiting a specialist and surgery are often so long that a patient may seek another European hospital overseas with a shorter waiting list.

Another consideration is that the UK healthcare system still has many problems, with underfunding being the most important. Guidelines and protocols differ in the UK. For instance, I read somewhere that the death of a patient in a ward can be confirmed without an electrocardiogram! In any case, although the UK system has myriads of standards, it is doubtful if they are all followed.  

The lack of a second medical opinion and avoidance of surgeries in the elderly! 

Often, people diagnosed with cancer or another severe disease, acute or chronic, do not seek a second medical opinion as either they neglect it or rely on and trust the first and single medical advice. 

Senior patients also have the right to a second opinion regardless of age, especially for life-threatening conditions. This is especially important when urgent or elective surgery is excluded. Otherwise, we can speak about a subtle form of euthanasia!  I recall a documentary about a senior British man who visited the ER suffering from mesenteric ischemia. Although this is fatal unless treated surgically, he was excluded from surgery due to various medical conditions (including epilepsy), i.e., comorbidities. Of course, he died. However, in this case, the patient had no choice but surgery, as no surgery condemned him to death. Things here are complicated, as many surgeons are assessed for their mortality rate and would avoid operations with a high mortality risk! But it should be the patient who should come first, not the statistics! 

I once asked a Southern European surgeon who works in the NHS if the elderly with cancer are treated as in his country. He replied that a surgeon in the UK might be reluctant to bring a senior patient into the operating room. However, in other countries, surgeons may be less reluctant! From my perspective, a relatively good cardiovascular condition and the lack of severe comorbidities should be considered in the elderly so that they are not excluded from surgery, at least in emergencies. 

Cardiovascular health should be investigated with ECG, Echocardiography, and pulmonary function tests, especially FEV1. That is especially important for life-threatening diseases such as cancer and CABG (coronary artery bypass) for heart problems. Of course, the patient will take the mortality risk. But the problem here is that if the mortality ratio of each surgery is documented, a surgeon will not be happy if a senior patient dies in the operating room (OR). Consequently, surgeons will discourage or refuse operations on elderly patients who otherwise are fit for surgery. That is a shortcoming of reporting mortality rates in operations.   

Doctors wearing casual clothes!

In the UK, you can see doctors without white coats or scrubs (like those surgeons wear). They simply carry a label with their name! Obviously, it is not for the benefit of the doctor's sanitation to wear casual clothes. A white coat protects the physician as well as the patient. From my perspective, wearing casual clothes with only an ID tag signifying that a person is a doctor is unacceptable. In the ER, at least an apron should be used for protection. 

They removed the lab (white) coat in the UK in 2007. But there are no convincing reasons for not wearing scrubs that are amazingly comfortable, speaking from my own experience!  Also, the UK has banned crocks (hospital-comfortable open shoes) since 2011! 

Doctors assessed strictly with an appraisal and revalidation system! 
Complaints against doctors just by clicking an option on the General Medical Council's webpage!

The appraisal and revalidation system has efficiently worked in the UK and should be an example for all countries. But the way that anyone can easily make a complaint by merely clicking the option on the General Medical Council may have, as a consequence, a doctor to incline to ''defensive medicine'' with an additional cost of unnecessary lab or imaging exams and interventions! 

Cost-effectiveness at the expense of human life?

A characteristic case of cost-effectiveness was during the coronavirus COVID-19 crisis that became a pandemic in the Spring of 2020. The UK delayed enormously imposing a lockdown, as it found it cost-effective not to do so! But when the death toll rose significantly, and even the Prime Minister was hospitalized in the ICU with pneumonia from the virus, it was then when they started some restriction measures! 

Notwithstanding, cost-effectiveness is mandatory as the health systems have already been brought to their knees because of the aging population. They struggle to provide expensive drugs, especially immunotherapy, which costs more than five hundred dollars per dose, while gene therapy, which costs 2 million dollars per dose, is inaccessible. However, this should not be done at the expense of the patient's safety, such as was in the controversy over depriving British patients of interferon for Multiple Sclerosis in the NHS. At the same time, in other European countries, it was widely used. A recent example is the new expensive meningitis group B vaccine that many health systems cannot afford, so families purchase it at their own expense. Concisely, cost-effectiveness should always be sought, but we should keep in mind that in medicine, humans come first, not the economy!

b) Why you should NOT choose the UK for specializing in medicine!

Overview

If you live in a Western country, you will waste your time if you choose the UK to practice medicine! Many people working in the NHS want to leave the system and travel overseas to a country with a better healthcare system! As I explained above, the NHS is on the verge of collapse or privatization! Regarding the NHS system, it is on the brink of collapse. Currently, hospital vacancies ask for experienced doctors, even in junior posts!

Competition

Competition for a medical post is very high, and the typical example that comes first to my mind is the UK, where there may even be some hundred applications for a single hospital post. In the last decade, competition has increased dramatically from international doctors, and this was aggravated by the migration surge towards Europe, referring to migrants from Europe (such as from the Balkans and Southern Europe) or migrants coming from countries outside Europe, such as from the Middle East, Asia, Africa, and even from South America!

So, foreign doctors participate as well in the reckless competition for the available hospital posts that, in this way, they become international! Because of the abundance of applicants, most of the available vacancies have been covered, while recently, most jobs appeal to higher-level doctors, specialists, and consultants. This is most striking in the UK.

Training (vs.) Service posts: wasting time on irrelevant, non-training posts until obtaining a specialty!

A problem standard in the UK is that most posts are not educational and Dean-approved but are service posts and consequently do not count in the estimation of the training years for completing a specialty! Most of the vacancies in the UK are LAS (locum appointment for Service) rather than LAT (locum appointment for Training). There is controversy over this matter, as some claim it is better not to have service posts, as all posts should be training. Doctors need training. There is controversy over the fact that posts that are not educational and Dean-approved do not count toward the overall period of medical practice. Regardless of service or training, all working years should be a specialization period.

Most NHS medical posts in the UK are service posts, so they do not have the educational and Dean's approval as training posts. So, even though the hospital says that they have a training aspect, it may or may not be a training post officially! That means that many doctors in the UK work in various service posts that are often irrelevant to the specialty they wish to practice. For instance, a doctor wanting to specialize in gastroenterology may practice medicine at various clinics, such as the emergency department, as most vacancies are clinical and require experienced doctors even at the Foundation Year 2 level! Usually, they demand recent NHS experience! Thus, a doctor in the UK may spend an overall 7 - 10 years on becoming a specialist, while in other countries, it may take only 5 to 6 years for most specialties!

Four-month contract, underpayment, and costly accommodation!

Another problem in the NHS of the UK is that most contracts are for four months to a maximum of one year. That means that usually, after four months, a doctor must change hospitals or reapply to the same one! Consequently, the medical training period is interrupted every 4 months until the adjustment to a new hospital.  

Additionally, many junior doctors complain that their wages in the UK remain low despite their strikes. But even for higher levels, the salary is not satisfactory concerning the highest wages in other Western countries or even the Middle East (such as in Dubai). Also considerable is the inflated cost of living in the UK, especially in London, where someone may pay nearly 1,000 dollars monthly to live in a small apartment! On the contrary, in the US, accommodation is more affordable to medics, while some may reduce costs by living with a roommate.

Overqualified doctors for junior posts!

The extreme number of international applicants in countries such as the UK means that many vacancies, even those involving junior doctors, are covered by overqualified doctors, even specialists! Qualifications such as MRCP exams and extensive experience are often desirable for posts referred to junior doctors, but they should not, as these are higher-level qualifications! 

A striking example that came to my attention was a service post (LAS) of Foundation Year 1 in general surgery in the UK that asked a trainee with clinical skills such as venipuncture, insertion of central lines, peritoneal drains, etc. These skills, of course, are extreme for a junior doctor on a foundation year one level. Referring to Foundation Year 1 posts, some vacancies require previous NHS experience. However, these posts apply to medical interns who are about to practice in hospitals without experience! Notwithstanding, as the number of medical graduates is high, especially from India, Pakistan, and Southeastern Europe, employers often ask for previous hospital working experience! 

All the above are related to the abundance of international doctors who apply for medical positions worldwide. Hence, hospitals are happy to use overqualified doctors for low-grade medical jobs, usually service posts, as the training educational and Dean-approved posts are the minority!  

The low wages of the medical staff and, in some cases, the unpaid overtime!

The salary of the medical professionals working in hospitals should be satisfactory. Otherwise, without a financial incentive, doctors feel frustrated, and their performance remains low.  In the UK, a junior doctor is paid only 25,000 pounds annually, nearly 32,400 dollars! With this meager income, a junior doctor should pay his or her numerous obligations. In the British NHS, things are predicted to deteriorate, as it is financially unsustainable, and some speak even about its (semi)privatization, as in the USA! 

In the last years, there has been a massive wave of medics from developing countries as well as from many developed countries (such as from Southern and Eastern Europe) aiming to work in developed countries such as in Southern and Central Europe and North America where they seek better wages in advanced health systems. 

Another issue is that some doctors may work overtime, but this extra workload may not be paid. 

Bank doctors with a ‘parachute landing fall’ to hospitals ‘when’ and ‘if’ they need them!

The new trend in the UK is the post of 'bank doctors.' No, they are not related to banks and finance! They are doctors who 'land with their parachutes' whenever and if needed ('when and if') to cover somebody's days off or leaves or in case a doctor is necessary for a specific clinic. So, these doctors do not have a particular residence, which raises the concern that a doctor comes to work in a hospital unfamiliar to them. Additionally, the bank post may be without a contract, meaning that the doctor can be easily fired!

Pre-interview via Skype or direct live interview?

When someone who has applied for a vacancy in countries such as the UK is called for an interview, it is prudent to ask for a video call pre-interview via Skype. This choice will prevent the applicant from wastefully spending money to travel to the UK and learning at the interview that they do not meet the elevated expectations of the hospital because most posts are covered by overqualified international doctors with sustained experience.

Vacancies for UK hospitals (application forms): could you tell me your ethnic origin, religion, and sexual orientation? 

When someone wishes to apply as a doctor for a hospital post in the UK, filling out the application form will meet the 'weird' question about their sexual orientation, religion, and ethnic origin! Recently, some vacancies ask asked if you intend to change sex, although changing sex is usually accompanied by changing the ID documentation.

The GMC (General Medical Council) asks the same to enroll as a doctor in the UK. For this article, I called the GMC and asked them why they asked these things, and they replied that they do it for statistical reasons to register the diversity. They assured me that this information was confidential. However, I still have not realized the necessity to ask these kinds of questions in the application form for a hospital post, and my consideration is primarily how an employer will assess this information. Apparently, this information is given to protect applicants from discrimination. But this should be obvious to everyone, regardless of providing or not this information. Protection should be provided anyway.

Difficult exams and certifications

Certifications, such as the MRCP (and FRCS for surgeons) in the UK, make things difficult for someone who wishes to complete a specialty and become a consultant. In the US and Canada, the USMLEs (steps 1, 2 & 3) tests are mandatory for someone who wishes to study medicine there. These difficult exams discourage many international students who want to live the American dream.

In the UK, most posts require NHS experience; many ask applicants to have passed the MRCP test (it has fees). Moreover, in the UK, the GMC (General Medical Council) needs, in some cases, the PLAB test. To prove English language proficiency, they need a remarkably high overall score of 7.5 and a minimum of seven on each of the four modules of the IELTS exams to enroll non-native speakers. However, it is not easy to achieve in ''writing part 2,' i.e., the essay! Surprisingly, the GMC does not recognize the US TOEFL exams, as if in the USA, they are speaking Chinese! Obviously, this happens because the IELTS was created by the UK and Australia! It should be mentioned that in the IELTS exams, the exam graders spare high grades in the essay, at least those equal to or higher than seven, which is the required grade in the ''writing'' part! 

c) Why you should NOT choose Australia & the USA for specializing in medicine!

Overview

Many international doctors, including those working in the NHS, consider Australia a place to specialize in medicine. This decision may be the right choice for specialists. But the decision for international medical graduates to take exams to specialize in Australia is a waste of time and money! The same is true for taking the USMLEs to practice medicine in the USA. 

Australia

A doctor from Finland who now practices medicine in Australia as a GP recommends choosing another country! You may read her daunting experience on What is some advice about an AMC (Australian medical certificate) especially sources of studying?

If you wish to take exams to specialize in medicine in Australia, you will waste your time and money! The pass rate for the MCQ exams is 58 percent. If you pass them, you will have only a 28 percent possibility of passing the clinical exams! The MCQ exams are supposed to equal the level of an Australian graduate. But this can be doubted, as these exams ask for information that only a generalist would know, not even a GP or an internal medicine doctor! They ask for things from all fields, including surgery, general practice, internal medicine, pediatrics, psychiatry, obstetrics, and gynecology. The MCQ tests are delivered in a 3.5-hour session. That means you will have 84 sec to answer each of the 150 questions that may be difficult! For example, you may even be asked to interpret a CT scan! That means whether an Australian medical graduate has an excellent theoretical and clinical knowledge of all specialties or the exams are an excuse for the AMC to decrease the passing rate to a dwindle! The latter seems more reasonable. 

The AMC in Australia accepts without exams only medical graduates who have practiced medicine for at least one year in the UK. It also accepts medical graduates from New Zealand, Canada, or the US who do not need to take exams. They may ask some candidates to pass the PLAB test. But medical graduates from countries other than the above are asked to sit written (like USMLEs in the US) and clinical (like PLAB test but harder) exams that are costly. Obviously, the system does not give a damn if you come from a Western country, as you will take costly exams along with medical graduates from developing countries. 

In other words, it is as if they consider European medical graduates incompetent, asking them to take exams along with candidates from developing countries, including India, Pakistan, Bangladesh, countries of Africa, non-EU members from the Balkans, etc. Also, as mentioned, the success rate is low, and the whole preparation to take exams means a waste of time and money.

The total cost for this venture (exams, books, traveling to Australia for the clinical test, and paying all the required fees) with a low probability of success is at least 5,000 US dollars! Additionally, the system requires one year of clinical practice in Australia! But these posts are scarce. Perhaps it was something like rural service in the past, but recently, vacancies can be found everywhere, not only in the provinces. The Australian Medical Council, apart from IELTS, recognizes TOEFL (IBT), but it needs an extremely high mark on the ‘’writing’’ section (essay). It should be mentioned that the British and Australians have created the IELTS test, which explains why they prefer their exams to other international ones! In the IELTS exams, the exam graders spare high grades in the essay, at least those equal to or higher than seven, which is the required grade in the ''writing'' part! 

The USA 

It is doubtful whether the US healthcare system is the best. It may not even be satisfying! The question is, who does the rating? The evaluation of a healthcare system should be performed by independent international authorities, such as the World Health Organization (WHO), rather than local, such as NICE in the UK.

In the US, the Medicare system is manipulated by insurance companies that aim to spend less on patients’ treatment. This tactic adversely affects their health when important lab and imaging tests and interventions are omitted! Additionally, before the ‘Obama Care’ in 2010, uninsured patients had no access to healthcare, while those treated for emergencies were dumped from the hospital after recuperation! US resident doctors (not specialists) are also said to be treated like slaves!

The latest statistics in the US show, as in the UK, that the figures are unsatisfactory. Americans' new average life expectancy is 78.7 years, ranking the US behind other developed nations and 1.5 years lower than the Organization for Economic Cooperation and Development (OECD) average life expectancy of 80.3!

In the US, before Obamacare, uninsured patients were dumped from hospitals after receiving first aid! Statistics show that healthcare expenditure in the US is the highest compared to other countries. However, a considerable proportion of the population, including children and the impoverished, are uninsured or ''under-insured''! For example, this may be an individual's choice to work without insurance in a job or as a freelancer, with the former being illegal and the latter a reckless decision that the uninsured will understand eventually when he or she becomes old or if an unexpected illness or injury comes.  

Putting all together, an ideal system is between private and public, with cooperation in receiving patients and undertaking lab and imaging exams. 

The USMLE exams to practice medicine in the US

In the USA, international medical graduates need to sit the USMLE exams, which are costly. As in Australia, the system does not give a damn if you come from a Western country, as you will take the extravagant exams along with medical graduates from developing countries! The rate of success is better than in Australia. Nevertheless, the whole preparation to take exams is a waste of time to prepare for the 2 steps and a waste of money to pay the fees.

d) Private vs. Public healthcare: Which system is to the benefit of the patient?

Let us imagine a patient who suffers from a medical problem and is hospitalized. In a public hospital, the patient will be treated well. Still, when the hospital is overcrowded, less attention may be paid, and earlier discharge may occur, as every empty bed is valuable! Suppose the patient needs to be hospitalized in an ICU (intensive care unit). In that case, specific criteria may exclude him or her, such as extreme age, ominous prognosis, if the illness is incurable, etc. 

Suppose the same patient is hospitalized in a private hospital and can afford to pay his or her expenses without the interference of a private insurance company. In that case, the patient can receive optimal treatment in a well-organized private hospital with more skilled doctors (mostly specialists), and ICU admission criteria may be less strict! However, in case the private hospital's expenses are paid by a private insurance company, then healthcare may be suboptimal, as the insurance company will cut many costs that are not always unnecessary. That means the patient will receive at least the basics. However, depriving the patient of the expensive lab and imaging tests or access to the ICU (in which the daily cost is enormous, for example, it may be $ 3,000 per day) may affect the outcome. 

As mentioned above, the ideal system may be between a private and a public healthcare system. But as public or private insurance is associated with pensions and healthcare, things are more complicated, and since the population is aging, it may render unsustainable as in the UK! 

e) Is there an optimal Western healthcare system?

I am unsure if there are any satisfying Western healthcare systems, as the problem is who does the rating, i.e., if it is independent. In any case, countries such as Scandinavia, Canada, Australia, and New Zealand allocate public funds from taxation to finance their national health system to which everyone has free access. These countries have succeeded in providing a satisfying level of effective healthcare for their citizens, not theoretically as in the UK. In contrast, the NHS system still has many problems, with underfunding being the most important. 

Conclusion

Although an Australian, I advise international medical graduates against choosing the UK, Australia, or the USA to specialize in medicine as they do not show they need them! From this advice, specialists are excluded. Regarding the UK, the NHS system is on the verge of collapse, while they currently ask for experienced doctors even for junior posts! In Australia and the USA, foreign graduate doctors who wish to specialize there need to take costly exams regardless of graduating from a Western or a developing country! The success rate in Australia is low, while the fees are exorbitant. Doctors should choose other Western countries that really need them, such as Sweden! 

Thanks for reading!