International medical graduates: lessons from the past and hopes for the future.

The high levels of unemployment among international medical graduates (IMGs) in the UK and the skewed career structure of the NHS may stem from the 1930 withdrawal of General Medical Council recognition for Indian degrees forcing Indian colleges to align more closely with Western medical practices. From 2001 emigration to the UK surged just when UK medical schools were increasing their output. The result was severe unemployment among IMGs. The visa restrictions put in place to correct this make it difficult for IMGs to come to the UK even for short periods of experience. However, the Medical Training Initiative visa category offers an alternative and allows them the opportunity to gain up to two years' UK experience. The NHS has been in debt to IMGs and the countries that trained them since its inception. We must look for new ways to maintain international links and for the NHS to play a positive role in the global health economy.

Clinical attachments: fond farewell or new beginning? A survey of the attitudes and practice of medical consultants and international medical graduates.

OBJECTIVES: To analyse the experience of clinical attachment (CA) of international medical graduates (IMGs) and consultants. DESIGN: Analysis of questionnaires and CVs. SETTING AND PARTICIPANTS: 573 IMGs applying for a house officer post and 102 consultant physicians working in North East England. RESULTS: IMGs had spent a mean of 16 months unemployed, of which 3.8 months was spent on CAs. The median number of CAs was two and the average number of applications sent before obtaining a CA was 73. 90% of IMGs found their CA helpful and 57% would not take up a post without a CA first. Criticisms related to lack of responsibility, isolation and poor job prospects. 90% would apply for honorary posts if advertised. 73% had received induction at the onset of placement, but only 32% had been assessed at the end. 50% of consultants took CAs and only 4% were thinking of stopping doing so. Those without CAs blamed work pressure (43%) and pressure from their employer (23%). CONCLUSIONS: There are deficiencies in pastoral care, the application process and assessment, but CAs are valued by IMGs and offered by half the consultants surveyed. New immigration rules will mean fewer IMGs will come to the UK, but CAs will be needed by those that do, as well by refugees and European Economic Area (EEA) graduates. The tradition of CAs for international graduates could be used to accommodate those coming to the UK on exchanges and scholarships and form part of the recently announced Medical Training Initiative for IMGs.

Assisting international medical graduates applying for their first post in the UK: what should be done?

The number of international medical graduates (IMGs) passing the Professional and Linguistic Assessment Board (PLAB) examination was six times greater in 2004 than in 2000. This has resulted in unprecedented numbers of applicants for junior posts, with some attracting over 1,000 overseas graduates. The Royal College of Physicians working group on IMGs was established in 2004 to address the problems that face newly qualified IMGs. The group has ascertained and now publishes current levels of competition for junior posts in order to inform overseas graduates of the levels of competition they are likely to encounter. The group is seeking ways of selecting applicants when such large numbers apply for posts and is looking at ways of improving clinical attachments. The paper considers these and other difficulties that IMGs face when they first seek employment in the UK and discusses possible solutions.

Number needed to sacrifice: statistical taboo or decision-making tool?

UNLABELLED: The percentage that benefit from medical preventive measures is small but all are exposed to the risk of side effects so most of those harmed would never benefit from their use. There is no expression or acronym to describe the ratio of harm to benefit nor discussion of what level of harm is acceptable for what benefit. Here we describe the harm to benefit ratio (HBR) expressed as number harmed (H) for 100 to benefit (B) and calculated for commonly used medical interventions. For post TIA carotid endarterectomy the HBR is 25 (25 postoperative strokes or deaths are caused for 100 to be stroke free at 5 years); warfarin in atrial fibrillation in patients aged under 65 results in 400 intracerebral haemorrhages for every 100 saved from a thromboembolic event; fibrinolytic treatment for stroke causes 44 symptomatic intracranial haemorrhages for every 100 that have minimal disability at 3 months; aspirin in high risk patients causes 33 major bleeds for every 100 occlusive vascular events prevented; routine inpatient thromboprophylaxis causes 133 additional bleeds for every 100 pulmonary emboli prevented; breast cancer screening causes 1000 unnecessary cancer treatments for 100 cancer deaths to be prevented. CONCLUSION: The HBR or number needed to sacrifice is larger than most imagine. Its wider use would allow us better to recognise the number harmed, allow better informed consent, compare different preventive strategies and understand the risks as well as benefits of preventive treatments.

A randomized questionnaire-based study on the impact of providing numerical information on colorectal cancer screening.

OBJECTIVES: To establish whether the provision of numerical data using pictograms and framed as event rates affects subjects' attitudes to colorectal cancer (CRC) screening. DESIGN: Randomized questionnaire and telephone study comparing a control group given standard NHS CRC information leaflets with an intervention group given the same leaflet but enhanced with additional numerical and pictorial information. SETTING: District General hospital and two general practices in North East England. Study carried out immediately prior to the introduction of CRC screening. PARTICIPANTS: A total of 478 non-gastroenterological subjects (age range 60-70 years). MAIN OUTCOME MEASURES: The difference in the two groups' overall wish to be screened; comparison of the impact of enhanced vs. unenhanced summary points in the NHS information leaflet; the summary point that most influenced their decision on screening; the views of the intervention group on the additional numerical and pictorial information provided. RESULTS: A total of 256 (54%) responded (124 from the control group and 117 from the intervention group); 22% were interviewed by telephone; 90% of the control group and 85% of the intervention group wished to be screened (P = 0.34). Provision of numerical and pictorial information significantly changed the impact of five of the six summary points on the decision to be screened. Sixty-two percent of the intervention group found the pictograms helpful while 83% of those interviewed by telephone found the numerical data helpful; 73% of the control group when given by telephone the additional numerical information given to the intervention group said this would have been useful in aiding their decision-making. CONCLUSION: Providing additional numerical information would enhance the credibility of the screening programme without necessarily reducing the numbers screened.

"The cry of a trapped heart".

We present a case referred for endoscopy because of symptoms of dyspepsia and abnormal liver function tests. These more obvious symptoms masked an underlying history of shortness of breath on exertion and mild bipedal oedema. Physical examination revealed a raised jugular venous pulse with pulsus parodoxus, hepatomegaly, mild ascites and slight bipedal oedema. Investigations confirmed the presence of idiopathic calcific constrictive pericarditis. An early surgical pericardiectomy led to resolution of symptoms and signs, and a normalisation of liver biochemistry.