Prospects and challenges for an Indian dermatologist in the United Kingdom
Of late, several Indian dermatologists have been exploring work opportunities in the United Kingdom (UK). This article aims to provide an overview of the prospects, requirements, career options, and challenges an Indian dermatologist might encounter in their journey to become a part of the National Health Service (NHS), UK.
In the UK, there is a state-funded system called the NHS, which guarantees care for all. That means everything from ambulance rides and emergency room visits to long hospital stays are all free. They are paid for with payroll taxes. Private health care also exists in the UK, which is paid out of pocket or through private insurance coverage, but only a small minority of residents opt for it. Each NHS system uses general practitioners (GPs) to provide primary health care and to make referrals to further services as necessary. The first point of contact for a patient will be their local GP who is usually able to treat the patient. However, if the condition requires specialist intervention, then they may refer the patient to a community dermatologist (often private – but NHS funded) or to the secondary care (hospital) dermatologist. According to the 2019 statistics, there is one work time equivalent dermatology consultant per 80,000 of the population – 17,500 above the British Association of Dermatologist’s recommended target. As evident, dermatology is a busy department in the NHS.
DESCRIPTION OF A TYPICAL NHS TRUST
Usually, a hospital will be under an NHS trust – the one we work in is the East Kent Hospitals NHS University Foundation Trust. We have five main hospitals under it and the staff is expected to work at two sites. Most hospitals in the UK, including ours, do not have dermatology wards and offer only outpatient dermatology services. Apart from general outpatient dermatology services and ward referral from other departments, most trusts also run various clinics which cover phototherapy, patch testing, biologic services, vulval and penile dermatology clinics, pediatric dermatology, urgent skin cancer clinics, nurse- and doctor-led surgery clinics, and Mohs surgery.
SPECIALIST TRAINING IN THE UK
The training in the UK is different to that in India. Here, after medical school, one must complete 2 years of foundation year training (F1 and F2). If one wants to become a dermatologist, one must do 2 years of general medicine training, otherwise known as core medical training 1 and 2, pass the Membership of the Royal Colleges of Physicians (MRCP) of the United Kingdom examinations and then apply for specialist training. All entries are subject to interview and previous show of interest like research in the chosen subject. The MRCP (UK) examination has three parts. Part 1 and 2 are multiple-choice question (MCQ) style papers and the third part, known as Professional Assessment of Clinical Examination Skills, is a practical examination. The Indian dermatology qualifications are not considered equivalent to that of the UK as the medical training for 2 years is lacking. To get included in the General Medical Council (GMC) specialist register, one has to either retrain in the UK or apply for a Certificate of Eligibility for Specialist Registration (CESR).
CESR involves collecting evidence within the past 5 years and demonstrating the equivalent knowledge and experience in dermatology as laid out in the UK dermatology curriculum. CESR application currently costs £1640. One must also collect evidence for medical training. This entails spending time in the medical wards and clinics so that the medicine competencies can be signed off. Some doctors also successfully clear MRCP (UK) alongside to boost their chances in the CESR. Most doctors also attempt the Specialty Certificate Examination (SCE) in dermatology. This examination is conducted once a year. Candidates in the UK training posts normally take the SCE in their penultimate year of higher specialty training. The SCE is held throughout the UK and in a wide range of international venues. It is in an MCQ format comprising 200 questions pertaining to the UK dermatology curriculum. At present, around 67% of dermatology applicants successfully become consultants through the CESR route.
WHERE TO BEGIN
So, where does one start their journey to the UK?
The first step to be able to start working in the UK is to obtain the GMC license to practice. There are two ways to do this. One way is to pass MRCP (UK) which tends to be time consuming. The alternate and preferred route involves passing the Professional and Linguistic Assessments Board (PLAB) examination. Additional qualifications such as European Diploma in Dermatology or Dermatopathology are not accepted for obtaining the GMC license.
Step 1: English language competency
One needs to clear the academic module of the International English Language Testing System with a total score of at least 7.5 and an individual score of at least 7 in each of the three sections (listening, reading, and writing). The other option is to pass the medicine version of occupational English test and obtain at least a Grade B in each section. Now, one is eligible to apply for the PLAB 1 examination.
Step 2: PLAB 1
PLAB 1 examination covers the common, important, or acute conditions seen by trainees entering the 2nd year of the Foundation Programme, and the management of long-term conditions seen in primary care. The examination fee is currently £235. This is an objective examination with 180 MCQs to be completed in 3 h. The passing mark is set each year according to the level of difficulty of the examination. There are numerous online resources to prepare for the examination. This examination is also presently held in New Delhi, Chennai, Kolkata, and Mumbai. After passing PLAB 1, one is eligible to apply for PLAB 2.
Step 3: PLAB 2
PLAB 2 is an Objective Structured Clinical Examination. The examination fee is at present £860. It is made up of 18 scenarios, each lasting 8 min and aims to reflect real-life settings including a mock consultation or an acute ward. The candidate must meet the set passing score and clear a minimum of 11 stations to achieve an overall pass. This examination is held only in the UK (Manchester or London) and hence requires a visa to take it. It is suggested that as soon as the PLAB 1 results are announced, the candidate must start planning the date they wish to take PLAB 2 and book the examination early as the dates get blocked. One usually applies for the standard UK visa which currently costs £95. In general, candidates form online study groups and tend to prepare for and take the examination around the same time. After passing PLAB 2, one can apply for the GMC license to practice.
Step 4: GMC license application
One should have their application for registration with a license to practice in the UK approved within 2 years of passing PLAB 2. International medical graduates applying for provisional or full registration with a license to practice need to have their primary medical qualification independently verified before they are granted registration. Verification is carried out by the Educational Commission for Foreign Medical Graduates through their online system known as the Electronic Portfolio of International Credentials (EPIC) service. This currently costs $125 to open an EPIC account and $90 per credential verification.
Once you have your license to practice, you can start applying for jobs. Some choose to start their career as a core medical trainee, wherein they gain medicine experience and pass MRCP (UK) simultaneously. Thereafter, they attempt to enter the UK training program in dermatology which is for 4 years. However, the success rate for this is low as dermatology is a sought-after branch in the UK. Therefore, most Indian dermatologists choose to apply for Staff grade, Associate Specialists and Specialty doctors (SAS) jobs or locum consultant positions according to one’s experience. These posts do not require the applicant to be on the GMC specialist register. The advantage here is that the doctor can work in dermatology and simultaneously gather evidence to become a consultant dermatologist through CESR. Jobs are usually sought through various job portals, of which the most popular are NHS jobs and Oriel. Once a job is secured, the visa for the doctor and their family will be sponsored by the trust.
A typical job plan for a full-time consultant/SAS doctor comprises 10 professional activities of 4 hours sessions each. Clinical sessions include general clinics, skin cancer clinics, or surgery lists. A full-time consultant does five clinical sessions while a SAS doctor does seven clinical sessions in a week. The remaining sessions are for administration, supervision, governance, and continuing professional development (CPD). During the administration sessions, one is expected to answer to queries from patients/GP, analyze histopathology reports, and communicate the results and treatment plan to patients/GP through letters. This is done using voice recognition software.
CPD is any learning outside of undergraduate education or postgraduate training that helps one maintain and improve their performance. It covers the development of one’s knowledge, skills, and attitude across all areas of their professional practice. One can attend various seminars and teaching programs conducted by different dermatological societies and the Royal College of Physicians.
Weekly multidisciplinary meetings are conducted, in which the treatment of skin cancer patients (including melanomas, squamous cell carcinomas, porocarcinomas, and so on) is discussed along with representatives of other specialties such as pathology, maxillofacial surgery, general surgery, and oncology.
Once a month, most departments have a business meeting to discuss targets, income, and expenditure. This is followed by a joint clinical and histopathology session, in which patients with either unique or difficult to manage conditions are discussed.
Typical working hours for a dermatologist are 9 am–5 pm, Monday to Friday. All clinics are pre-booked, and an average clinic runs for 3.5 h. There are usually about six new and six review patients in one session. The consultation time generally allotted for a new patient is 20 min and 10 min for a review patient. After the consultation, a letter describing the diagnosis and management is dictated which is electronically sent to the concerned GP.
Full-time doctors are entitled to 25–32 days annual leave and 8 public holidays depending on their grade. Consultants and SAS doctors also get 10 days paid study leave and an annual allowance of £1000 to spend on different study courses.
Most applicants from India are well trained in cosmetology. However, if one wants to pursue a career in cosmetology, then UK is not the right place to be in. NHS does not fund any cosmetic procedure. If a patient wishes to take any cosmetic treatment including chemical peels and laser hair reduction, they will have to do so privately. Private clinics offer cosmetic treatments but are expensive. Although there are successful overseas dermatologists running private cosmetology clinics, a handsome capital is required to do so.
INCOME AND EXPENSES
Doctors are paid well in the UK. The starting annual salary of a consultant is around £80,000 and can go up to/more than £100,000. You can also join the pension scheme to which the trust contributes as well.
The income tax is nearly 40% and the living expenses are high. Apart from rental, council tax and utilities, parents must factor in the childcare expenses. The schools have holidays for 1–2 weeks every 6 weeks excluding the 6 weeks of summer vacation. Childcare can include hiring a child minder, after school clubs, and holiday clubs all of which incur additional cost.
Every system has its pros and cons. Working in the UK can be a unique experience with access to various expensive treatment options such as biologics, exposure to skin cancer management, and plenty of opportunities for professional development. On the other hand, licensing examinations, CESR, limited cosmetology exposure, and high cost of living can be challenging. We hope this article sheds light on what lies ahead should you choose to join us in the NHS.
Declaration of patient consentNot required as there are no patients in this article.
Financial support and sponsorshipNil.
Conflicts of interestThere are no conflicts of interest.
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