This is a three-part series for American trained physicians wanting to live and practice medicine in the UK. In part one we introduced the National Health Service (NHS), in this second part we outline the UK medical education system. In the third part we will highlight the nitty gritty of transitioning to practice medicine in the UK. For reference, there is an appendix defining UK medical lingo at the end of this document.
Overview of Medical Training in the UK
Undergraduate Education: University/Medical School
University spans 6 years and is a combination of college and medical school. UK medical students study a lot for the first few years of school, but the expectation of them as medical students on the wards is extremely low. They don’t graduate with anywhere near the clinical experience as US medical students.
Doctors in training are referred to as ‘Trainees’. The length of training varies based on specialty though on average is 10 years. UK trainees can follow several pathways to become a General Practitioner (GP) or Consultant. At each stage of training, trainees belong to a deanery which organizes their educational experience and assesses their progress. The various pathways make it harder to compare and align US and UK medical education programs and make the transition from the US to the UK more challenging.
Students graduate from medical school and become a Foundation Year Doctor – a paid job! This is a two-year, general postgraduate medical training program, prior to entering specialist or general practitioner training.
Foundation Year 1: The trainee, previously known as ‘House Officer’, has a role similar to a third year medical student. This year provides a mix of general medicine, general surgery, and other specialties. The General Medical Council (GMC), the medical licensing body, provides a provisional medical license at the beginning of this year, and, if successful, a full license at the end of the year.
Foundation Year 2: The trainee, previously known as ‘Senior House Officer’, has a role similar to a fourth-year medical student. During this year the trainee experiences general practice, emergency medicine, psychiatry, pediatrics, OB/GYN, and other specialties.
Following the Foundation Years, the trainee applies for one of the following pathways which is similar to residency and fellowship.
This is a three-year core training program for those pursuing Acute Internal Medicine (most similar to Hospital Medicine), Emergency Medicine (EM), Intensive Care Medicine, and Anesthesiology. Trainees receive broad clinical experience in Emergency Medicine, General Internal Medicine, Anesthesiology, and Intensive Care Medicine. They then apply for specialty training (called getting a “specialty number”), to focus solely on EM or Anesthesiology etc. Successfully ‘getting a number’ means a trainee has obtained a specialty training spot similar to our fellowship training.
Internal Medicine Training (IMT) – Formerly known as Core Medical Training (CMT)
IMT training is for individual wishing to pursue further medical subspecialty training. This training is broken into two parts: core training, then subspecialty training. During two years of core training, the trainees rotate through 6 medical subspecialties lasting 4 months each. During this time, they must take and pass all 3 parts of the Membership of the Royal College of Physicians exams (MRCP). After passing all three parts of the MRCP (PACES), trainees may apply for a subspecialty training, called “getting a number”. Upon completion of the subspecialty training, trainees will receive a Certificate of Completion of Training (CCT). This means the physician is certified in that specialty and also in General Internal Medicine. A CCT in General Internal Medicine cannot be achieved on its own– it must be coupled with another specialty.
Run Through Training
This is for trainees pursuing Pediatrics, OB/GYN, Ophthalmology, Radiology, Cardiothoracic Surgery, Neurosurgery, and Academia. They will automatically progress through subsequent years of training until they complete specialty training.
GP training lasts 3 years and culminates in a Certificate of Completion of Training (CCT). After obtaining the CCT they are listed on the GP register. GPs are similar to an outpatient family medicine physician, caring for patients from birth to death – pediatrics experience is required. A General Practitioner with Extended Roles (GPwERs) is a GP with specialized training in a specific area such as women’s health, asthma or diabetes. Notably, Pediatrics in the UK is a purely inpatient specialty.
GP training takes about half as much time as the other routes and is a ‘Jack of all trades’. Their knowledge base is intentionally broad, requiring a basic understanding of disease processes, triage skills, and management of chronic diseases. The GP training path splits off early in a trainee’s career and is completely office based; GPs generally do not have the same level of knowledge as an American IM/FM attending.
This 2 year program and is for trainees wishing to pursue surgical specialties, such as urology or orthopedics Trainees may be called StR’s (Surgical trainee, prior were called SpR). During this time, they must take and pass parts A and B of the Intercollegiate Exams of the MRCS (Membership of the Royal College of Surgeons). Upon completion, trainees can apply for further surgical specialization.
A 3 year program provides broad psychiatric training for those wishing to pursue the psychiatry specialties. During this program trainees must pass the MRCPsych Exam (Membership of the Royal College of Psychiatrists). They can then apply for psychiatry specialty training in General Psychiatry, Child & Adolescent Psychiatry, Forensic Psychiatry, Old Age Psychiatry, Psychiatry of Learning Disability, and Medical Psychotherapy.
Each step of the GP/specialty training incorporates an annual assessment, called the Annual Review of Competence Progression (ARCP). As long as a trainee passes the ARCP, they progress to the next year of training. During the year before completion, trainees usually have a Penultimate Year Assessment, identifying gaps in their portfolio to address before becoming a consultant.
There is no ‘board examination’ in the UK. All exams are taken in training. In order to obtain a CCT and become a consultant, a trainee logs hours/patients/cases/etc, is assessed by other consultants, and must pass the ARCPs. Each specialty has a Decision Aid Tool, which can be found on the Joint Royal Colleges of Physician Training Board (JRCPTB) website. Trainees must meet the requirements in the Decision Aid Tool to achieve the CCT.
After obtaining the CCT, the physician joins either the GP register to be recognized as a General Practitioner or the GMC Specialist Register to be recognized as a consultant. Both are attending physicians who do not require supervision. Notably a specialist consultant is expected to provide subspecialty care and general medical care (hence the dual CCT of specialty & general internal medicine). As a consultant you will spend 50-75% of your time practicing clinically and the rest of the time assuming a leadership, management, and or education role. To obtain a consultant post, a doctor trained outside the UK must demonstrate equivalence to the UK training system – more on this in part three our series.
Appendix: Basic Lingo
ACCS– Acute Care Common Stem (prelude to Acute Medicine, Anesthetics, ITU, and Emergency Medicine)
ARCP: Annual Review of Competence Progression is an annual review of an individul’s progression through training.
CST: Core Surgical Training; 2 years of surgical rotations
CCT: Certificate of Completion of Training means the trainee has finished training and is are eligible to join the GP or Specialist Registers. This is equivalent to being an attending physician in your specialty.
GMC: General Medical Council is the governing body of safe medical practice for all doctors licensed in the UK. They provide licenses, certificates of good standing, and administer exams.
GP register– General Practitioner who has completed training, obtained a CCT. The GP equivalent of a Specialist Register.
IMT: Internal Medicine Training; formally known as Core Medical Training or CMT.
JRCPTB: Joint Royal Colleges of Physician Training Board, like the ACGME or AOA graduate medical education board for medical specialties. They dictate the competences for a trainee.
- Group 1 Specialties– Acute Internal Medicine, Cardiology, Clinical Pharmacology & Therapeutics, Endocrinology & Diabetes Mellitus, Gastroenterology, Genitourinary Medicine, Geriatric Medicine, Infectious Diseases (except when dual with Medical Microbiology or Virology), Neurology, Palliative Medicine, Renal Medicine, Respiratory Medicine and Rheumatology
- Group 2 Specialties– Allergy, Audiovestibular Medicine, Aviation & Space Medicine, Clinical Genetics, Clinical Neurophysiology, Dermatology, Haematology, Immunology, Infectious Diseases (when dual with Medical Microbiology or Virology), Medical Oncology, Medical Ophthalmology, Nuclear Medicine, Paediatric Cardiology, Pharmaceutical Medicine, Rehabilitation Medicine and Sport and Exercise Medicine.
- Clinical Oncology, Medical Microbiology, Medical Virology and Occupational Medicine will also recruit trainees who have completed the first two years of IMT. Trainees will also be able to apply for Intensive Care Medicine single CCT training after two years of IMT
MRCP: Membership of the Royal College of Physicians Exam. These are 3 separate exams, akin to our USMLE or COMLEX exams. Once completed, a trainee may apply for a subspecialist training number, aka ‘getting a number’.
NHS: National Health Service is the publicly funded healthcare systems of the United Kingdom encompassing NHS England, NHS Scotland, NHS Wales, and Health and Social Care in Ireland.
PYA: Penultimate Year Assessment is a meeting held the year prior finishing training identifying gaps in training that need to be addressed before obtaining a CCT.
Royal College of X: the specific governing body of a specialty, e.g. Royal College of Physicians, Royal College of Surgeons, etc. Governs the structure of what knowledge is required to learn about the specialty in order to be that kind of doctor, also has input into training for specialties
Specialist Register: Also referred to as ‘obtaining your CCT’, this is the achievement of finishing training and becoming a consultant in your chosen specialty.
Dr Yunger is originally from the US and completed her Internal Medicine training and board certification in 2012. She now lives and works in the UK.