When should I apply for a training post in medicine/ GP training?
This is frequently asked question by a lot of international medical graduates. The main reason they are in this cold and wet country is for training.
Usually, IMGs start as a non trainee and then apply for a training post once they have got used to the system.
However some have been encouraged to apply for training posts as soon as possible. This can pose some problems which I have noticed in colleagues who have applied for training posts pre-maturely.
1. Managing on calls
When you accept a training post, you are expected to be on the on call rota from the first day. You cannot say that you would like to observe your colleagues.
If you are not used to working in the NHS and doing on calls, you will not be to work efficiently. Unfortunately, things have changed a lot in the NHS - Efficiency is kety. We have to clerk patients, manage acutely unwell patients, ensure they are seen by a medical consultant ASAP and handover the least number of patients to the next team.
If we are slow (only because we have not done enough on calls) then this may pose a problem. We get nagged by consultants, registrars and our educational supervisors may be fed back about this. This is because of the immense pressure in the NHS to see, discharge or treat patients.
2. Communication.
We are in a new country, in a new culture and in a new system. Patient management here depends on team work and thus effective communication. If we are shy because we are not used to the NHS system, patient care is put at stake.
Common examples include:
Not asking the on call SHO to chase a troponin
Not referring a patient with STEMI to cardiology
Not discussing a sick patient with the consultant
Not informing a patient of what is going on.
We all feel uncomfortable doing this initially. We are not a full blown active SHO the day we start. We start as a very shy doctor and slowly, we become more and more confident. Some doctors become confident in a few weeks, some in a few months.
However, when we start in our training posts, we are expected to be on top of this. We should be able to manage acutely unwell patients, understand the importance of escalation and communication not only with the patient but with the MDT.
3. Errors
We all make mistakes. However some mistakes are more serious than others. There may be a lack of knowledge and experience. Yes, we have read all about DKA in text books during medical school however in the NHS, we have a proper protocol for DKA and we are expected to follow it. When I started here, despite me knowing about DKA, I would have not been able to manage a patient safely had I not had the knowledge about DKA pathways in my trust.
The errors increase when we are stressed. And we are the most stressed when we are on call. Therefore it is very important to have knowledge about everything - whom to ask for help. Knowing that your trust has DKA pathway rather than downloading a random trusts DKA pathway from the internet ( which may be old or may not be relevant).
4. Getting the most out of your training post.
You should have cleared most of your exams, should be confident to work as a SHO in order to get the most out of your training post. This does not mean that you should waste 3 years to complete your MRCP - rather give your part 1, and if possible part 2 before you start your IMT training post so that you have only PACES to focus on during your training ( however please note that IMT is now 3 years so you can easily give one part of your MRCP each year - or within a year).
You should also have enough time to get your curriculum signed off for your ARCP ( http://omarsguidelines.blogspot.com/2018/06/arcp-in-core-medical-training.html).
If you are not confident then you will waste precious time worrying about things you should have sailed through just by a bit of more experience in the NHS as a non trainee.
Here are some frequently asked questions
LOL! A non trainee and a trainee have equal responsibilities.
Yes, I understand. However when it comes to on calls, a non trainee can easily inform the rota team and HR ( on accepting the job offer) that (s)he is not comfortable doing on calls and would like to shadow his/her colleagues.
Hahaha! We all still have to manage patients even if we are non trainees.
Yes, this is true but the expectation is different. Ideally, a non trainee should be supported when (s)he starts and slowly ( in a few days to weeks) can easily see patients on the ward on his/her own.
What world do you live in? When I started, I was doing on calls on my first day and was all alone on the ward as a non trainee!!!
All non trainees who have just started in the NHS must inform the HR and rota team when they accept the job (ideally at their interview) that they would like to shadow on call doctors and their colleagues in the ward before they are allowed to start independently.
This is stupid! I know the whole of Oxford Handbook of Clinical Medicine and I will manage easily.
I understand that you are a very bright doctor and I do not doubt your knowledge. However it is "logistics" which we need to understand. I will give you an example. A patient comes in with confusion, and is on warfarin. He had a fall 3 hours ago. You have appropriately requested a CT head on your trusts computers. However you fail to call the on call radiologist to vet it urgently and then inform the CT scan room about it. This is missed and the patient has a "non urgent" scan the following day showing a massive bleed which could have been picked up earlier and discussed with the neurosurgeons earlier.
Also, you failed to handover the clotting to be chased to the on call team and as a result the patient had a INR of 6 which could have been reversed earlier.
This is a simple case which we, as a SHOs see all the time in the NHS. We can manage all of this within a hour if we have the right "logistical knowledge".
As a trainee GPST1/CT1/IMT1, you will be expected to have this "logistical knowledge".
I am very good at my communication skills. I got a 9 in my IELTS.
Again, I have no doubt about your language skills but the on calls can be very overwhelming. Especially during handover when the next team wants to start as quickly as possible. You need to have a good knowledge of SBAR so that you can do an efficient handover.
Non training posts are a complete waste of time.
When you start training, you will realize that training posts are the same with the additional nuisance of completing the tick box exercise for your ARCP every year. Honestly, you need to change your mindset. You will definitely be able to survive in the NHS however you will not be a happy doctor. Get the most out of your non training post.
What can I do during my non training post then?
1. Get used to the on calls in the NHS - You should be on the "on call block/on call rota" and should be able to confidently see patients.
2. Get used to teaching - take this opportunity to gain confidence in teaching medical students. You will have medical students shadowing you a lot during your training posts.
3. Get used to a QIP/Audit - You will have do a QIP every year and complete it before your ARCP.
4. Attend teaching sessions - You will gain knowledge.
5. Be an active member of the MDT - communicate with nurses, OTs, PTs, discharge coordinators. Lead the ward MDTs
6. Try to give a post graduate exam - like MRCP 1 if possible.
7. Get an e portfolio ( http://omarsguidelines.blogspot.co.uk/2017/03/maintaining-your-e-portfolio.html ) or use paper based portfolios just to familiarize yourself with how it works.
But this is what the training post is all about! Making me more confident.
Yes, however as a GPST1/IMT1/CT1 you should be as confident as a foundation year 2 doctor who has completed his/her foundation training. This is what you will be expected to be.
Oh I have got my foundation competencies signed off anyway!
Getting your competencies signed off is very easy. Your consultant will happily do it. However it is all about personal confidence and "logistical knowledge" I explained about earlier - No one will be able to judge you except yourself.
And as you might be aware, there is a new form out and hence you cannot use your old competency form. I have explained it here:
https://omarsguidelines.blogspot.com/2019/10/the-2020-foundation-competency-crest.html
Nowadays IMT/GPST/CT training posts are more easily available than non trainee posts.
This is true in a way - the reason behind this is that British Medical Graduates prefer to do non training posts as they do not want to go through the stress of maintaining their portfoilios, ARCP, exams and this way they have more time to decide which speciality they want to go for. Hence, they do non training FY3 year after completing their foundation programme. There are plenty of openings for IMGs for training posts.
Do you think that CMT is stressful?
I am now a core medical trainee year 2 and given that I worked for 18 months as a non trainee SHO with access to NHS e portfolio during my non training post, I was easily able to settle in my core training post. I also gave my MRCP 2 exam before my core medical training.
This way, I was able to enjoy my training post and get the most out of it ( ie I was able to prepare myself for ST3).
So what is your final advice?
I am not asking you to stay in a non training post forever. I want you to apply for a training post whenever you feel ready. Remember, IMT/GPST posts are easily available however you can struggle to progress in them if you do not have enough experience to juggle your training needs and clinical side ( AKA service provision- doing on calls, working on understaffed wards).
I want to specialize in medicine. What should I do?
Work in a non training SHO post, see if you can pass your MRCP 1, ALS, do a QIP, do teaching sesssion, maintain a portfolio ( paper based or e portfolio) and then apply for IMT.
This can be 6 months into your post or like me, 1 year into your post. Remember that your post will start in August.
I want to become a GP.
You need to have passed your ALS, done teaching and ideally, done a taster session in GP (just to have an idea about it). You should be confident on your on calls so that when you start your GPST1 post, you are equivalent to your core trainee/IMT colleagues when it comes to "logistical knowledge".
Why have you made this post?
Because I am seeing more and more IMGs getting complaints (ranging from minor to major ones) because they are not used to the system of the NHS. They get stressed on their on calls and make mistakes. All of this can be avoided by a bit of more time doing on calls as a non trainee.
Other points which my colleagues have pointed out:
"I think it's very essential that IMGs attempt to gain a UK driving license before training.A GPST friend who doesn't have a license has to cover 4 hospitals in 4 different cities,sometimes 2 sites in one day and she's not finding it easy meanwhile her colleagues are coping"
All I am suggesting is that when you start your IMT/GPST1 post, you will be on calls. In order to avoid stress and a potential complaint, you should be confident enough as a SHO to be able to manage patients efficiently and safely. This can be easily achieved in 6 months to a year of working as a non trainee SHO.
Usually, IMGs start as a non trainee and then apply for a training post once they have got used to the system.
However some have been encouraged to apply for training posts as soon as possible. This can pose some problems which I have noticed in colleagues who have applied for training posts pre-maturely.
1. Managing on calls
When you accept a training post, you are expected to be on the on call rota from the first day. You cannot say that you would like to observe your colleagues.
If you are not used to working in the NHS and doing on calls, you will not be to work efficiently. Unfortunately, things have changed a lot in the NHS - Efficiency is kety. We have to clerk patients, manage acutely unwell patients, ensure they are seen by a medical consultant ASAP and handover the least number of patients to the next team.
If we are slow (only because we have not done enough on calls) then this may pose a problem. We get nagged by consultants, registrars and our educational supervisors may be fed back about this. This is because of the immense pressure in the NHS to see, discharge or treat patients.
2. Communication.
We are in a new country, in a new culture and in a new system. Patient management here depends on team work and thus effective communication. If we are shy because we are not used to the NHS system, patient care is put at stake.
Common examples include:
Not asking the on call SHO to chase a troponin
Not referring a patient with STEMI to cardiology
Not discussing a sick patient with the consultant
Not informing a patient of what is going on.
We all feel uncomfortable doing this initially. We are not a full blown active SHO the day we start. We start as a very shy doctor and slowly, we become more and more confident. Some doctors become confident in a few weeks, some in a few months.
However, when we start in our training posts, we are expected to be on top of this. We should be able to manage acutely unwell patients, understand the importance of escalation and communication not only with the patient but with the MDT.
3. Errors
We all make mistakes. However some mistakes are more serious than others. There may be a lack of knowledge and experience. Yes, we have read all about DKA in text books during medical school however in the NHS, we have a proper protocol for DKA and we are expected to follow it. When I started here, despite me knowing about DKA, I would have not been able to manage a patient safely had I not had the knowledge about DKA pathways in my trust.
The errors increase when we are stressed. And we are the most stressed when we are on call. Therefore it is very important to have knowledge about everything - whom to ask for help. Knowing that your trust has DKA pathway rather than downloading a random trusts DKA pathway from the internet ( which may be old or may not be relevant).
4. Getting the most out of your training post.
You should have cleared most of your exams, should be confident to work as a SHO in order to get the most out of your training post. This does not mean that you should waste 3 years to complete your MRCP - rather give your part 1, and if possible part 2 before you start your IMT training post so that you have only PACES to focus on during your training ( however please note that IMT is now 3 years so you can easily give one part of your MRCP each year - or within a year).
You should also have enough time to get your curriculum signed off for your ARCP ( http://omarsguidelines.blogspot.com/2018/06/arcp-in-core-medical-training.html).
If you are not confident then you will waste precious time worrying about things you should have sailed through just by a bit of more experience in the NHS as a non trainee.
Here are some frequently asked questions
LOL! A non trainee and a trainee have equal responsibilities.
Yes, I understand. However when it comes to on calls, a non trainee can easily inform the rota team and HR ( on accepting the job offer) that (s)he is not comfortable doing on calls and would like to shadow his/her colleagues.
Hahaha! We all still have to manage patients even if we are non trainees.
Yes, this is true but the expectation is different. Ideally, a non trainee should be supported when (s)he starts and slowly ( in a few days to weeks) can easily see patients on the ward on his/her own.
What world do you live in? When I started, I was doing on calls on my first day and was all alone on the ward as a non trainee!!!
All non trainees who have just started in the NHS must inform the HR and rota team when they accept the job (ideally at their interview) that they would like to shadow on call doctors and their colleagues in the ward before they are allowed to start independently.
This is stupid! I know the whole of Oxford Handbook of Clinical Medicine and I will manage easily.
I understand that you are a very bright doctor and I do not doubt your knowledge. However it is "logistics" which we need to understand. I will give you an example. A patient comes in with confusion, and is on warfarin. He had a fall 3 hours ago. You have appropriately requested a CT head on your trusts computers. However you fail to call the on call radiologist to vet it urgently and then inform the CT scan room about it. This is missed and the patient has a "non urgent" scan the following day showing a massive bleed which could have been picked up earlier and discussed with the neurosurgeons earlier.
Also, you failed to handover the clotting to be chased to the on call team and as a result the patient had a INR of 6 which could have been reversed earlier.
This is a simple case which we, as a SHOs see all the time in the NHS. We can manage all of this within a hour if we have the right "logistical knowledge".
As a trainee GPST1/CT1/IMT1, you will be expected to have this "logistical knowledge".
I am very good at my communication skills. I got a 9 in my IELTS.
Again, I have no doubt about your language skills but the on calls can be very overwhelming. Especially during handover when the next team wants to start as quickly as possible. You need to have a good knowledge of SBAR so that you can do an efficient handover.
Non training posts are a complete waste of time.
When you start training, you will realize that training posts are the same with the additional nuisance of completing the tick box exercise for your ARCP every year. Honestly, you need to change your mindset. You will definitely be able to survive in the NHS however you will not be a happy doctor. Get the most out of your non training post.
What can I do during my non training post then?
1. Get used to the on calls in the NHS - You should be on the "on call block/on call rota" and should be able to confidently see patients.
2. Get used to teaching - take this opportunity to gain confidence in teaching medical students. You will have medical students shadowing you a lot during your training posts.
3. Get used to a QIP/Audit - You will have do a QIP every year and complete it before your ARCP.
4. Attend teaching sessions - You will gain knowledge.
5. Be an active member of the MDT - communicate with nurses, OTs, PTs, discharge coordinators. Lead the ward MDTs
6. Try to give a post graduate exam - like MRCP 1 if possible.
7. Get an e portfolio ( http://omarsguidelines.blogspot.co.uk/2017/03/maintaining-your-e-portfolio.html ) or use paper based portfolios just to familiarize yourself with how it works.
But this is what the training post is all about! Making me more confident.
Yes, however as a GPST1/IMT1/CT1 you should be as confident as a foundation year 2 doctor who has completed his/her foundation training. This is what you will be expected to be.
Oh I have got my foundation competencies signed off anyway!
Getting your competencies signed off is very easy. Your consultant will happily do it. However it is all about personal confidence and "logistical knowledge" I explained about earlier - No one will be able to judge you except yourself.
And as you might be aware, there is a new form out and hence you cannot use your old competency form. I have explained it here:
https://omarsguidelines.blogspot.com/2019/10/the-2020-foundation-competency-crest.html
Nowadays IMT/GPST/CT training posts are more easily available than non trainee posts.
This is true in a way - the reason behind this is that British Medical Graduates prefer to do non training posts as they do not want to go through the stress of maintaining their portfoilios, ARCP, exams and this way they have more time to decide which speciality they want to go for. Hence, they do non training FY3 year after completing their foundation programme. There are plenty of openings for IMGs for training posts.
Do you think that CMT is stressful?
I am now a core medical trainee year 2 and given that I worked for 18 months as a non trainee SHO with access to NHS e portfolio during my non training post, I was easily able to settle in my core training post. I also gave my MRCP 2 exam before my core medical training.
This way, I was able to enjoy my training post and get the most out of it ( ie I was able to prepare myself for ST3).
So what is your final advice?
I am not asking you to stay in a non training post forever. I want you to apply for a training post whenever you feel ready. Remember, IMT/GPST posts are easily available however you can struggle to progress in them if you do not have enough experience to juggle your training needs and clinical side ( AKA service provision- doing on calls, working on understaffed wards).
I want to specialize in medicine. What should I do?
Work in a non training SHO post, see if you can pass your MRCP 1, ALS, do a QIP, do teaching sesssion, maintain a portfolio ( paper based or e portfolio) and then apply for IMT.
This can be 6 months into your post or like me, 1 year into your post. Remember that your post will start in August.
I want to become a GP.
You need to have passed your ALS, done teaching and ideally, done a taster session in GP (just to have an idea about it). You should be confident on your on calls so that when you start your GPST1 post, you are equivalent to your core trainee/IMT colleagues when it comes to "logistical knowledge".
Why have you made this post?
Because I am seeing more and more IMGs getting complaints (ranging from minor to major ones) because they are not used to the system of the NHS. They get stressed on their on calls and make mistakes. All of this can be avoided by a bit of more time doing on calls as a non trainee.
Other points which my colleagues have pointed out:
"I think it's very essential that IMGs attempt to gain a UK driving license before training.A GPST friend who doesn't have a license has to cover 4 hospitals in 4 different cities,sometimes 2 sites in one day and she's not finding it easy meanwhile her colleagues are coping"
All I am suggesting is that when you start your IMT/GPST1 post, you will be on calls. In order to avoid stress and a potential complaint, you should be confident enough as a SHO to be able to manage patients efficiently and safely. This can be easily achieved in 6 months to a year of working as a non trainee SHO.
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