Classroom versus clinical experience

For all participants, a greater exposure to patients in clinical practice made it easier to recall information when answering AKT questions.

‘You need theory obviously but the practical exposure makes you remember because there are so many things to remember in medicine.’ [Female, IMG]

Clinical exposure to specialties or specialty topics

Limited clinical exposure to a host of specialty topics, including rheumatology, ophthalmology, paediatrics (managing medical conditions affecting infants, children and young people), gynaecology, relating to sexual health or radiology, provided difficulties answering questions for all participants.

‘To be honest with this particular question, I haven’t seen a vulva inflamed with ulcers. It’s more my, the clinical approach that medical training has given me to say a patient presenting with these symptoms what is the likely cause’.[Female, BME UKG].

‘I haven’t actually come across this before in practice [osteoporosis assessment]. For me probably more theoretical. I’m not 100% sure of the answer to this.’[Male, UKG].

IMG participants reported feeling at a greater disadvantage, because of less exposure to certain specialty topics at undergraduate level, and for some also during UK training.

‘Because for some people if you are coming from outside Europe, they don’t see any CT [Computed Tomography] in real life. The knowledge about it is just like my teacher taught me while standing in front of the board, in front of the classroom.’[Male, IMG].

Textbook learning and memorisation

IMG participants demonstrated how ‘rote’ learning defined as repeated rehearsal of verbal material helped them to answer specific AKT questions compared with UKGs.

‘We are taught to memorise things. Even if they don’t make sense. The more you memorise, the better. So we used to memorise all the doses and names.’ [Female, IMG].

Some IMGs felt disadvantaged by theoretical and rote, since rehearsal stored the information without attaching meaning to it.

‘All my knowledge is theory based. So I don’t get that feel I know it.’ [Female, IMG].

Recency

All participants reported that lengthy intervals between learning and assessment negatively affected their ability to recall information to answer AKT questions.

‘I haven’t done maths or calculations since high school. Maybe sixteen years.’ [Male IMG].

‘This is going back years of what did I learn in medical school about ophthalmology.’ [Female, BME UKG].

‘This national guidance, I haven’t looked specifically at recently. Perhaps looked at it a while ago.’ [Female, UKG].

IMG participants were at a greater disadvantage compared with UKGs because some had not revisited AKT topics since their undergraduate training abroad.

‘I’ve got no clue currently. I haven’t worked in paediatrics or come across this [UK training]. When I was in basic training seven years ago [overseas], that’s the time I read about vaccinations. I have forgotten.’ [Male, IMG].

‘Since I’ve been to this country, I’ve never had any training about ophthalmology. The only training I’ve had about ophthalmology was at medical school and it was just for briefly; two or three months. That’s it.’ [Female, IMG].

GPSTs are known to face greater difficulties if longer than 9 years has elapsed since medical school or their PMQ was obtained outside the UK.

Repeated exposure

For all, frequent exposure to a greater number of patients increased knowledge of different types of illness and reportedly increased recall when answering AKT questions.

‘Getting exposed to many different patients makes it easier to remember.’ [Female, IMG].

Limited opportunity for experience

Missed training opportunities through lack of rotation through specialties impeded successful training in all participants; they had been unable to access a range of hospital departments to gain clinical experience in particular curriculum areas (eg, obstetrics and gynaecology, paediatrics).

‘I’m not going to be doing a rotation through that. So whatever I’m going to get out of it will be personal study and gynaecological patients that come into the practice that I see and discussion with my trainers’ [Male, IMG].

Gender barriers

Gender was a barrier to performance in specific AKT questions for all participants. Male IMG participants were less likely to have attended female patients during training.

‘I think female doctors in practice tend to see more gynae related issues. It’s less awkward to be examined by a female than by a male. I’ve also heard about risk of complaint against the male doctor to sensitive females.’ [Male, IMG].

‘I’ve certainly seen a few ladies in the last few weeks with vaginal discharge.’ [Female, BME UKG].

‘I don’t really deal with prostate problems much being a lady doctor.’ [Female, UKG].

Uncommon presentations

All participants reported difficulties answering AKT questions from topics that were uncommon clinical presentations in general practice, specifically in minor specialties.

‘Neurology, I’m not sure in regard to AKT, which is a paper exam. More like facing an actual patient. Neurology is a difficult specialiity.’ [Female, IMG].

Statistical learning

All participants expressed that there were limited opportunities for learning statistical aspects of the curriculum but data interpretation and statistics were areas where IMG doctors felt they required additional training support because of limited opportunities to learn statistics at undergraduate level.

‘As an undergraduate I never went through statistics. No!’ [Male, IMG].

As a result IMG participants found data interpretation questions difficult compared with UKGs.

‘We are not exposed to things like this (in under graduate training). Statistics is not new to us but not in this context. It’s not in the context of writing it out and explain. Putting in a graphic or table form. Not something we are used to. Nothing like this. I don’t know (if I want to have a go at it)’. [Male, IMG].

IMG candidates worried about examination timing which also dissuaded them from answering complex data interpretation or statistical questions.

‘I’ve done statistics before, not things they used in medicine and clinical trials, sensitivity and specificity. That was new to me.’[Female, UKG].

‘I’m just thinking I’ve never come across such a question (statistics). Or such a table should I say. I haven’t seen this particular table before.’ [Female, BME UKG].

Relevance to general practice

All participants struggled with questions relevant for minor specialty areas, administration, or where a referral would be made for secondary and tertiary care treatments. The questions were felt to be irrelevant to the work of a GP and were expected to be carried out by other health professionals (eg, nurse, midwife or pharmacist) or specialists.

‘Tend to refer most of them to opticians. Who will then refer to ophthalmologists as required?’ [Male, IMG].

‘I think it’s more a nurse’s role. The midwife.’ [Male, IMG].

Statistical relevance

This was particularly the case for statistics where participants felt questions were less relevant to daily practice.

‘Most of the time (statistics) I don’t need it in real life’. [Female, IMG].

‘This is just looking at data. I would never be asked this question. I can’t imagine I would ever be asked this by a patient’ [Male, UKG].

Participants generally expressed a dislike for statistics questions and felt unsupported in preparing for these.

‘I certainly know some friends of mine who would have a heart sink moment with this question. Even though they trained in this country, because they hate maths. They would rather have a clever pharmacist work it out.’[Female, BME UKG].

‘For all of us it’s all about stats. Probably we all chose medicine to avoid maths, I don’t know. For us it’s always the same. Everyone always talks about stats. Nobody likes it. We feel it’s very abstract. We feel it doesn’t relate to what we are doing at all. Medicine is more about treatment for us and stats should be left for the pharmacists or the researchers. For us it’s too abstract.’ [Male, IMG].

IMG participants in particular did not understand the relevance of learning statistics until they had begun training in the UK. This affected their motivation, confidence and attitude towards calculation-based questions.

‘So during my course of training I’ve had two day courses on statistics but I was thinking do I really need it? I wasn’t taking it seriously.’[Male, IMG].

‘Because I studied overseas, we didn’t have much statistics. When we actually started studying for AKT, we got to know that we need to study statistics.’ [Female, IMG].

‘Already looking at this I’m getting scared. Looking at these numbers.’ [Male, IMG].

Exam scenarios versus real life

All participants reported how in routine practice they could access the British National Formulary or National Institute for Health and Clinical Excellence (NICE) guidelines whereas this was not possible during the AKT, the examination setting itself being seen as a barrier.

‘This is more of an exam scenario because I would just have to be able to know it whereas in real life I can look it up with the patients.’ [Female, UKG].

‘I would find this question more appropriate for real practice if I had been asked a patient has this symptom and these are the possible investigations that you can do, which one would you do?’ [Female, BME UKG].

Participants felt that a drug calculation in the exam was unrealistic as part of a routine consultation.

‘More for exam. If I am sitting in a clinical setting with a ten minute consultation, what am I going to gain doing the maths while the patient is sitting there?’ [Male, IMG].

Perception of competence

Participants were sometimes overoptimistic when answering questions, presuming they had answered correctly, when in fact they had responded incorrectly. The types of language that over optimistic participants used when answering questions, for example, related to gender, to liking and being excited about the question, answering with much certainty, or stating the option was definitely correct.

‘Ok, drug side effects. I think I’m excited about this one. It has a lot to do with pharmacology drugs which I like. I like looking at the BNF and drug books just to look at the side effects. Just looking at this topic of drug side effects, even though I have not gone through it, I think I feel a bit confident……Definitely it’s going to be A’[Male, IMG].

‘So immediately it’s a thirty year old lady and again I’m comfortable answering this question perhaps more than male doctors because I get this problem presented to me. Not exactly this case but I have had this type of problem before presented in clinics. Before even looking at the options, it strikes me as a risk of an STI.’ [Female, UKG].

Biased self-evaluations

Participants’ estimates of knowledge, whatever their ethnic background, did not always correspond with their level of performance. Participants did not always recognise when their decision was correct or incorrect but some were worse at distinguishing between correct and incorrect responses. The types of factors that led to participants overestimating knowledge (when answering incorrectly) were related to previously having read about the topic or being familiar with it in clinical practice.

‘I like these ones (item stems, drug side effects) because they are straightforward. Only one can be correct….I’ve read about it. Done it in questions. Presented in surgery. I’m doing psychiatric now, and I’ve actually seen someone actually on a day to day basis’ [Male, IMG].

‘Yes, they are common drugs. All things I am familiar with. Atenolol, I prescribe every day.’[Male IMG].

Unfamiliarity with the NHS

IMG participants reported additional challenges including adapting to NHS culture, the style of teaching and learning, and a new language.

‘People from administration were saying it will take a few days but it’s not a few days, its months for you. To get used to the system and learn. But it was a bit difficult. Especially the first year I would say.’ [Female, IMG].

‘If you are not familiar with the system, you don’t know what services are available.’ [Female, IMG].

Abbreviations

Abbreviations were identified as a particular problem.

‘And even the simplest things. Abbreviations for example. Talking about patients. We don’t use abbreviations a lot from where I come from.’ [Female, IMG].

National guidance

IMG participants expressed having to adapt from a disease-centred model of care in their home countries to a model that embraced guidance which they were unfamiliar with overseas.

‘I think guidance are used more in the UK. So I still have to read a lot of guidance. Back where I trained, I don’t think national guidelines apply.’ [Male, IMG].

‘In some areas of Africa, we focus more or less on malaria and other infections. Some of the things we do know about. You give this. Give this. But over here everything is very rigid. So you couldn’t get to that NICE guideline of what is expected of you at a particular time.’ [Male, IMG].

IMG participants were unfamiliar with NICE guidelines before training in the UK, expressing concerns that guidelines were a ‘new thing’ for them.

‘Because I was trained overseas, the Ghana is quite different to what it is over here. Coming to work in the UK, you need to be working with the NICE guidelines. So I have not been, when I was in training, I have not been introduced to it. So it is a new thing I have been picking up after my graduation while working in the UK.’ [Male, IMG].

Item stems and options in the AKT referred to UK current national guidance and IMG candidates expressed that without an adequate length of training in the UK these types of questions were more difficult.

‘If I had come from overseas last year and I was sitting this exam this year, I probably will struggle because overseas we don’t follow UK guidance. This question is more relevant for people who were trained here. So guess ‘A’.’[Female, IMG].

Many participants had not read national guidance (NICE) on specific AKT topics and UKGs also lacked knowledge of specific guidelines.

‘Obviously I know the national guidance but I haven’t read the specific guidance of osteoporosis and menopause.’ [Female, BME UKG].

IMG participants highlighted lack of teaching on NICE guidelines during undergraduate and UK training and they required time to learn this.

‘Yes. It’s so much. Especially when you are a trainee: you are so busy with a lot of things. Especially if you are attached to a hospital job: you are so exhausted when you go home.’ [Female, IMG].

‘For the start of exam preparation, I probably need to cram a few guidance like…but it’s difficult to memorise what all the guidance are for everything.’ [Female, IMG].

For all participants, examination conditions differed from clinical practice, where doctors could refer to documents such as NICE guidelines.

‘It’s something that if I was with a patient, I would check the guidelines.’[Female, UKG].

Examination format

IMG participants highlighted unfamiliarity with the question formats used. This was compounded by the difficulties of translating their thoughts from their native language when answering AKT questions, despite having competent to good levels of English according to their International English Language Testing System scores (table 1).

‘Because of that you may not get the right answer. Most of us who are not trained here when we read the question will have got a bit of three way translation. We understand the English but we are thinking in our own native language’. [Male, IMG].

‘I trained in Russia in Russian language [native language African], so sometimes I have to think allowed and try to process the information before I totally understand it.’ [Female, IMG].

‘Maybe the UK graduates studied here and easier for them: the language is their language. They understand things easily. For us, we have to convert and think in our language to understand because we are trained like that.’ [Female, IMG].

This created discussions around additional time needed for IMG participants.

‘We take a little more time than them maybe. But I have seen UK graduates also failing AKT. So we can’t say that also’. [Male, IMG].

‘They need time for to understand what that means. But we haven’t got that. We are given the same time as someone whose language is English.’ [Male, IMG].