Is the PLAB Exam Any Good, or Just Good for Business?

The GMC is stalling on replacing the PLAB exam with the UKMLA, why?

In order to the register with the GMC, International medical graduates (IMGs) must pass the two-part professional linguistics and assessment board (PLAB) exam. Since 2017, from the GMC’s own data, there has been an extraordinary rise in the number of candidates applying for registration through the PLAB exams. This has translated to a significant increase in revenue for the GMC from £4 million in 2017 to £25 million in 2024.

Part 1 of the PLAB is usually taken in the candidate’s own country and is compromised of 180 multiple choice questions. To sit PLAB2 you need to take a flight to rainy Manchester. The exam contains 16 stations testing history taking with actors taking the role of patients. For both exams, up to five sittings are permitted.

What’s the Aim?

The GMC’s own executive summary into the PLAB states that the exam is ‘designed to test candidates’ ability to practice medicine at the level expected at the end of the F1’. This is a subtle but incredibly significant insight, as many see the PLAB exam as akin to UK medical finals, when in fact it benchmarks against the competence of a doctor who has already completed a year of supervised NHS practice.

That year is incredibly valuable for UK graduates in teaching them the nuances and subtleties of the UK healthcare system. Despite the GMC’s best efforts, it is unreasonable (and frankly impossible), to expect them to create a single exam that replicates this lived, workplace based training.

Evidence of Underperformance?

Studies have tried to identify how PLAB graduates fare in postgraduate training by comparing them with their UK graduating peers. One frequently cited paper found that IMGs who had passed the PLAB scored, on average, more than one standard deviation below UK graduates in postgraduate assessments such as the MRCP and MRCGP.

The paper suggested that this difference could easily be narrowed if the pass mark of PLAB1 and 2 were raised. Given the reach of this study, the GMC themselves make reference to it by responding that the PLAB exam is not designed to identify whether candidates have the potential to match UK graduates in postgraduate exams, it is simply designed to test candidates against the benchmark of whats expected of them at the end of F1.

This is technically correct, but dodges the fundamental question: At a time when UK graduates are becoming increasingly disgruntled at the difficulty of acquiring a training post, should the gateway to practicing in the UK be lower than the standard expected in the exact same system?

Why The Gap?

So why do IMGs underperform in these postgraduate examinations? A significant confounder here is likely to be one’s command of the English language, which leads one to struggle, particularly in viva or OSCE based exams. Needless to say, many IMGs go through an arduous process to acquire GMC registration through the PLAB, they pay examination and travel fees that can be equivalent of months of pay back home and work up to 100 hour weeks in difficult conditions whilst balancing examinations.

This is undeniable and deserves respect, but does not mean that the significant attainment gap can be ignored, especially when so many UK-trained doctors are struggling to secure precious speciality training posts.

The GMC also attempted to provide an explanation and on page 9 of their report they state: “Without an explanation for the reasons, we were unable to recommend a definitive, appropriate and proportionate course of action. We recommend that the GMC and other parties investigate further as to why PLAB candidates underperform in these postgraduate examinations and ARCP”. Well thanks for brilliant insight GMC.

A Simple MLA Based Solution

To many, there seems to be a simple, standardised solution to the discrepancy presented by the data: Standardise all exams for UK graduates and IMGs by rolling out the UKMLA to all international doctors. The GMC planned to replace the PLAB with the new MLA in 2024, but this was ultimately delayed with no further comment on their plan going forward.

The rationale for this delay seems to be rooted in its logistical and financial difficulties. With over 19,000 international applicants alone last year, scaling up a single, standardised OSCE/Viva based exam seems to be giving the GMC nightmares.

Things are always easier said than done, but for the On-Call team, widespread adoption of the UKMLA for all doctors wishing to hold a GMC license is the only option that balances fairness with safety.

On The Record: Where Do Doctors Stand When Patients Press Record?

You invite the next patient into your afternoon clinic; before they even take their seat, their phone is on the desk, recording. “I hope you don’t mind doc, I often forget what’s been said at the doctors”. This isn’t something you’re used to. On the surface, it doesn’t feel like the patient is guilty of any wrongdoing, but it just feels wrong and intrusive. What are your rights here?

Doctors are encouraged to enable patients to take recordings even if some find it intrusive. The BMA and medical defence bodies advise doctors not to object as most patients simply want to replay advice later. For most doctors, the fear is that the recording may be used to launch a litigation complaint, but the BMA advises that even if a recording were used in a complaint or legal case, you have nothing to fear if your practice is professional and your notes are complete.

The argument that banning something only drives people to do it secretly also applies here. The BMA believes that banning patient recordings would make covert, sneaky recordings more likely, causing greater damage to the doctor-patient relationship.

If it still unsettles you, it’s reasonable to sensitively explore why the patient is recording, but unless another colleague is available and happy to step in, you are encouraged to do your best fake-smile and proceed as normal.

Sick of Typing? There’s a Cure for That

Years ago, arriving on the ward as fresh-faced FY1, I was immediately struck by how much of the job resembled that of a human typewriter, rather than a doctor, the job I thought I had trained for.

The ‘quick whip round’ of the post-ops or the ‘speedy’ 4:57pm review of the ward patients so often meant that I had to stay back late, not to care for patients but just to finish documentation.

COWs (Computer on Wheels) were meant to be the answer, but between logging in, wheeling around, and batteries dying, they are generally slower-moving than their mooing namesake.

Fast-forward many years and apart from now occasionally being the type of last-minute reviewing senior I had previously loathed, not much has changed. Documenting is still the bane of my days, but this time it’s clinic.

In classic NHS fashion, 12 patients have been crammed into a session that would be tight for 10. Knowing that many of the patients will have waited for months to see me, I try my best to give them all my full attention.

So, as the clinic slides further and further behind schedule, I frantically type up clinic letters after each patient in a futile attempt to catch up. I rarely succeed.

Until now, there was no better way to do things… apart from the obvious of course – increased staffing, more admin support and longer clinic slots, but these elements remain beyond most settings.

But, barring widespread structural changes to the NHS (which also appear to be running behind schedule), I’ve found the next best thing. Accurx Scribe*.

Accurx Scribe sits in the Accurx App and now all I do is tap once and talk as I normally would, and at the end the conversation gets turned into structured notes or a clinic letter. Honestly, it’s as magical as getting a cannula in first time after the anaesthetist just failed. You should try it.

To start using Accurx Scribe download the Accurx App today and enjoy leaving work on time.

*Accurx Scribe is powered by Tandem which is registered as an MHRA Class I medical device - meaning it’s legal to use in the clinical setting and compliant with NHS guidance

I’m Guessing You Want Someone Who Knows About the Brain, Not Balls…

Just another on-call tragic comedy

There are certain rites of passage in medicine that only us doctors can converge upon. These experiences bind more than any exam or induction ever could. Forget the noble ‘saving-lives’ stuff, we are talking about the tales where if you don’t laugh, you’ll have to cry.

A Wake-Up Call From Lazarus

One time I was approaching the end of a long and exhausting set of nights as an F1 covering the medical wards. Half an hour before the end of my shift, I was summoned to certify the death of an elderly lady who has lost her battle with a nasty pneumonia.

As I gently pushed open the door, I found her entire family gathered around the bedside, their faces being illuminated only by the soft light of the lamp in the corner. I closed the door behind me and the beeping of the NIV machines disappeared and there was a strange stillness to the room. I apologised to the family for their loss, whilst pulling up a chair and placing my stethoscope on the patient’s chest.

The chest is silent, no breathing or cardiac sounds. I could never remember exactly how long you were meant to listen, so I go with the ‘long-enough until it gets awkwardly long, then a bit longer’ approach. Silence… until suddenly I was interrupted by the loudest, deepest gasp from the supposedly deceased patient.

My head jolts back, stethoscope flying out of my ears. To this day, I’m not quite sure how to describe the noise I made in that moment, let’s just say I hope never to run into that family again. I ended up providing some good entertainment in handover to the day team.

Last gasp apparently or maybe even Lazarus syndrome (aptly named from a biblical story): some rare phenomenon where you get a delayed return of spontaneous circulation after cessation of CPR. Given my patient did not make another breath after that, I am going with the last gasp theory.

No, Urology With a ‘U’

I am a step closer to completing the Urology bingo card after that week of on-calls. After a morning that consisted of treating a chap who seemed to be loosing half his blood volume through his urethra, I received another ‘urgent’ bleep from a colleague. I sat through a quite beautiful handover from this doctor detailing that their patient was suffering from an ischemic infarct.

In my naivety, I remained on the edge of my seat throughout his whole handover to find that the kidneys, ureter or penis does not make its way into the story. The referring doctor must have thought I was doing a hell of a systems review asking all those urological questions before realising where the issue had arisen here. If in doubt blame switchboard.

The next day I submitted my quality improvement project where the intervention was making switchboard clarify whether the caller wants Urology or Neurology. Outcome: 12 hour reduction in wasted time. At least it earned me a poster presentation…

“21:19 and the location is the Paediatric Assessment Unit. Patient X’s mother is insisting that she would never vaccinate her children again: ‘You don’t really know what these vaccines do to you.’ As she finishes, a vape makes an appearance from her back pocket. Is it home time yet?”

“No good, long term decisions were ever made following a set of nights”

“My favourite medicine-related quote of all time comes from Voltaire: The art of medicine consists of amusing the patient while nature cures the disease.”

“I’ve done more NIPEs than I can remember and it’s so easy to turn the steps into a formality after doing it hundreds of times. Last week I had my first coarctation and it did a great job of focusing my attention once again on each step. I’ll never forget how important those femorals are now”

“No longer speaking to my mate after he said my day job consists of asking teams to do 100 weird blood tests before giving prednisolone - I’m not even going to tell you my speciality”

What’s on your mind? Email us!

Some things to review when you’re off the ward…

Aspirin monotherapy has long dominated the post-MI care world, but a recent Lancet publication was unveiled to the cardiology world at the European Society of Cardiology congress in Madrid recently. The paper found that Clopidogrel is more effective (with no added risk).

Look out for an On-Call review of the new NHS trust rankings next week but for the meantime, here is a link to find out how your trust is facing a relegation battle in the table.

Weekly Poll

Last week’s poll:

Does your direct clinical and/or personal experience support or refute the idea that long COVID has a psychosomatic element?

…and whilst you’re here, can we please take a quick history from you?

Something you’d like to know in our next poll? Let us know!

Are Medical Stereotypes Innocent Jokes or Misleading Goads?

Which doctors don’t know the classic medical speciality stereotypes: from the tall orthopaedic surgeon with a huge personality and 200kg bench press PR, to the caffeine-fuelled, Hoka-wearing, triathlon-loving anaesthetist in lycra.

Where do these clichés come from, and are they harmless jokes or subtle barriers for medical students choosing careers? After the iconic 2011 BMJ Christmas paper that compared the intellect of orthopaedic surgeons to that of Ox’s, some medics were less than impressed.

In response, they conducted a study that suggested orthopaedic participants scored higher on average in IQ tests than anaesthetists. Granted, this is just one study, and IQ tests have their limitations, but the underlying question is worth asking: do stereotypes shape perceptions of specialties and the people who choose them?

We humans naturally categorise. It’s an evolutionary shortcut to make sense of the unknown. The “chicken or egg” dilemma applies here too as undoubtedly some personalities are drawn to certain specialties (your classic introvert is probably more likely to pick histopathology than paediatrics), while those specialties may perpetuate specific traits as like-minded colleagues cluster together.

Ultimately, most jokes wouldn’t be funny without an undertone of truth, but these stereotypes should remain light-hearted and a classic example of medic humour. Please don’t base your career choices around them.