🌍 International Medical Graduates
📥 Downloads
Handouts, resources, and teaching extras — curated over years, ready when you are. Print them. Share them. Stick them in a tutorial.
path: IMGs
- 8 ways for trainers to help their IMG trainees.doc
- cultural adjustment for the overseas trainee - a personal view.doc
- helping international medical graduates - scotland.doc
- helping international medical graduates - yorkshire.doc
- img new starter baseline form.docx
- international medical graduates.ppt
- quick tips for trainers with IMGs.doc
- some useful things to know about IMGs - their perspective.doc
- spend a penny and other things patients say - by jill choudhury.pdf
- the csa and IMGs by celia roberts - notes to powerpoint.doc
- the csa and IMGs by celia roberts.ppt
🌐 Web Resources
A hand-picked mix of official guidance and real-world IMG support. Because the best pearls are never all in one official document.
📚 Core Handbooks & Guides
🏥 Understanding the NHS
🗣 English Language Support
🤝 Support & Career
❓ Who Are IMGs and Why Does This Page Exist?
An International Medical Graduate (IMG) is a doctor who trained at a medical school outside the UK. You may be from India, Pakistan, Nigeria, Egypt, Romania, Sri Lanka, the Philippines — or any of 81 other countries currently represented among UK GP trainees. The term is used to describe a group that education systems want to support — not to label, judge, or stereotype.
There is an important truth that this page starts with: IMGs are not underperforming because they lack intelligence or clinical ability. Less than 1% of the world's population hold a medical degree. You got here through intelligence, hard work, and considerable courage. The challenges you face in UK GP training are cultural, linguistic, and system-based — and all of them can be addressed.
The real problem is that UK GP training was largely designed assuming trainees already understand British communication culture, NHS systems, and the unwritten expectations of UK general practice. You are expected to navigate a system that was not designed with you in mind. This page is about making that visible — and doing something about it.
A note on the label "IMG"
The word can feel reductive — as if your entire identity is collapsed into where you trained. You are an individual, with your own skills, background, and story. But when medical educators use this term, they are almost always trying to identify a group they genuinely want to help succeed. The intention matters here.
⚡ Quick Summary — If You Only Read One Section
The essentials, distilled. For the night before a tutorial or the five minutes before clinic.
📊 Pass Rate Comparison — IMGs vs UK Graduates
AKT First Attempt Pass Rate
SCA / RCA First Attempt Pass Rate
Source: RCGP MRCGP Annual Report 2022–23. First-attempt data. The gap has been consistent across years.
🗺️ The 5 Core Things Every IMG Must Understand
- This is not a knowledge deficit. Most IMGs are highly knowledgeable. The gap is cultural, linguistic, and system-based — all of which can be learned.
- UK GP is different at its core. It is built on partnership, shared decision-making, and patient autonomy. Not on doctor authority. This is the biggest shift.
- AKT failures for IMGs are not primarily clinical. They happen in statistics, EBM, and organisational questions — topics often not taught in overseas medical schools.
- SCA failures for IMGs are primarily in Clinical Management and Relating to Others. Not Data Gathering. The consultation is there — but it is not tailored to the patient, and it misses the relational elements.
- Start early. Every skill on this page — linguistic capital, SCA style, NHS knowledge — takes months to develop. ST1 is the time to begin, not ST3.
📊 Understanding the Challenge — The Full Picture
Why does a differential in pass rates exist, and what does it tell us?
🗺️ The 4 Domains of IMG Challenge in UK GP Training
These four domains interact with each other. Address all four — not just the clinical knowledge component.
The dual-task challenge
In a 10-minute consultation, an IMG may be: managing the clinical problem, translating nuance between two languages, interpreting unfamiliar colloquial remarks, maintaining cultural face, and demonstrating UK-style communication — simultaneously. UK graduates do none of these extra tasks. Acknowledging this does not mean lowering the bar; it means understanding where support is needed.
Research finding: female IMGs tend to adapt more readily
Studies and observational data from GP training programmes consistently show that female IMGs find it easier to adapt to UK GP professional culture than their male counterparts. One likely explanation: in many countries, female doctors were not socialised into the high-authority, directive role that male doctors often occupied. The partnership and shared decision-making model of UK GP — which requires stepping back from a position of authority — therefore feels more natural. This is an observation from research, not a universal rule. Individual variation is enormous.
What the research shows
Studies show IMGs score comparably to UK graduates on clinical knowledge questions in the AKT — but significantly lower on statistics, EBM, and organisational content. In the SCA, the gap is in clinical management (tailoring the plan to the individual patient) and relating to others (consultation style) — not usually in data gathering. This is consistent across multiple research studies and RCGP annual report data.
Interesting finding: Female IMGs adapt more readily
Research consistently shows that female IMGs tend to adapt more easily to UK GP communication expectations. One likely reason: in many healthcare cultures, male doctors hold higher social authority and are accustomed to a more directive style. UK GP expects partnership and equality — a shift that may feel more natural to doctors who weren't used to high-authority roles in the first place. This is an observation, not a generalisation — individual variation is enormous.
🇬🇧 Understanding UK GP Culture
The biggest shift for most IMGs — and the one that changes everything else
The Fundamental Difference
In many healthcare systems around the world, the doctor is the authority. You decide. You advise. You prescribe. The patient trusts you and follows your lead. This is not a criticism of those systems — they often work well and reflect legitimate cultural values.
UK general practice is built on a different model. The GP is an expert who works with the patient, not on top of them. The patient has autonomy. They may decline your advice. They may have their own ideas about what is wrong and what should happen. Your job is to understand their perspective, integrate it into your thinking, and make decisions together — not simply to give a correct answer and move on.
This is not just exam technique. It is the actual culture of UK general practice. Patients expect it. The GMC requires it. The SCA assesses it. And it takes time to internalise — especially if you trained somewhere that optimised for different skills.
| 🌍 Many International Systems | 🇬🇧 UK GP Culture | 🎯 What This Means for the SCA |
|---|---|---|
| Doctor leads and directs | Doctor and patient are partners | Share decisions — "What are your thoughts on that?" |
| Patient presents; doctor solves | Explore the patient's ICE first | Ask what worries them before examining or advising |
| Emotional content = distraction | Emotional content = clinical data | Acknowledge feelings explicitly — don't skip past them |
| Good doctor = correct diagnosis | Good doctor = correct process + correct relationship | You can have the right answer but fail if you dismissed the patient |
| Patient compliance expected | Patient autonomy respected | Never say "you must do X" — say "I'd recommend X, but let's see what you think" |
| Prescribing = key output | Not prescribing is often the best option | Explaining why you're not prescribing can score as highly as prescribing |
| Senior hierarchy respected publicly | Openness to uncertainty valued | "I'm not sure yet, and here's what I'd like to do to find out" = strong performance |
The most common SCA failure pattern for IMGs
The consultation is clinically competent. The diagnosis is correct. The management plan is accurate. But the patient didn't feel heard, wasn't involved in the decision, and the consultation felt like being given a prescription rather than having a conversation. The examiner fails the candidate on Clinical Management and Relating to Others — not because the facts were wrong, but because the style was wrong. This is the most common pattern. It is entirely correctable.
Insider Tip — It's a habit, not a performance
Many IMGs try to "switch on" UK-style consultation skills for the SCA while continuing to consult differently in everyday clinic. This doesn't work — it shows. The skills need to become your default clinical behaviour. Start practising shared decision-making, ICE exploration, and empathic phrases in every consultation from ST1 onwards. By the time you reach ST3, they'll be natural.
🗣 Linguistic Capital — What It Is and How to Build It
Why "Be More British" is the Wrong Advice
Some trainees are given feedback that they need to be "more British." It's an unhelpful phrase — vague, slightly presumptuous, and it doesn't celebrate the immense cultural diversity that IMGs bring to UK general practice.
What people mean by this is usually something specific and learnable: linguistic capital.
Linguistic capital (Bourdieu, 1990) means the mastery of and relation to a language — not just vocabulary, but fluency of idiom, comfort with turn-of-phrase, ability to read tone and subtext, and understanding of non-verbal nuance. It is the difference between knowing English and knowing how English is actually used by British people in everyday life.
🏦 The Linguistic Capital Bank — What You Need to Invest In
Everyday words, medical terms patients actually use, colloquial expressions
"I'm a bit under the weather." "Spend a penny." "Can't complain." Understanding these is clinically important.
Understatement, indirectness, humour as deflection — British communication norms that differ from many other cultures
British patients often understate symptoms and feelings. "A bit uncomfortable" can mean severe pain. Learning to probe gently is essential.
Eye contact, physical distance, turn-taking in conversation — vary significantly across cultures
Dry, self-deprecating, often used to cope with difficulty. A light moment in a consultation can build enormous rapport.
📺 How to Build Linguistic Capital — Practical Steps
🌟 Why It Pays Off — Three Advantages of Building Linguistic Capital
Bourdieu's original thesis makes three specific promises for people who develop linguistic capital in a culture that was not their upbringing. They are worth knowing:
Anyone can acquire it — regardless of ancestry
Linguistic capital is not inherited. It is built. A doctor who grew up in a Tamil-speaking household, with Tamil-speaking parents, living in a Tamil community — can still develop strong English linguistic capital. It takes deliberate immersion over time, but there is no ceiling and no prerequisite ancestry. The potential is entirely yours.
- Watch British TV — especially soap operas
Eastenders, Coronation Street, Hollyoaks, even Doctors. These are not just entertainment — they are linguistic and cultural immersion. Talk about episodes with reception staff, colleagues, or British-born friends. Discussion builds comprehension.
- Widen your social circle beyond other IMGs
It feels safer to socialise with people from similar backgrounds — shared experiences, shared language, comfort. That is completely understandable. But cultural and linguistic capital grows through immersion. Make the deliberate effort to build British-born friendships too. Coffee, a walk, a meal — anything. Especially with people who aren't doctors.
- Try to speak English at home
Even with family. Even imperfectly. The brain absorbs patterns faster when they're used in real emotional contexts — not just work. Practise with your children if you have them.
- Read novels set in the UK
Fiction gives you cultural context that a textbook never will. How do British people think about class, embarrassment, stoicism, humour? British authors write it instinctively. You'll absorb it through reading.
- Study the resource "Spend a Penny and Other Things Patients Say"
In the downloads section above — by Jill Choudhury. This is a gem. It covers the things patients say that are not in any clinical textbook, but that you will encounter every week in practice.
Recommended Book — For IMGs Developing Consultation Skills
Good Practice: Communication Skills in English for the Medical Practitioner by Marie McCullagh and Ross Wright. A superb teaching resource specifically designed for doctors working in English-speaking environments. Well worth the investment.
London Deanery DVD Resources
Words in Action — Uses real consultations recorded in multi-cultural Lambeth to examine what goes on in conversations with patients who speak limited English or have very different communication styles. Doing the Lambeth Walk — A companion resource for doctors new to UK practice, covering consultation skills in English, managing consultations, and shared decision-making. Check with your deanery or programme director for access to these resources.
🏥 How the NHS Works — What Every IMG Must Know
The NHS is unlike almost any healthcare system in the world. It is free at the point of use, funded by taxation, and organised around a primary care gatekeeper model. Understanding it is not optional — NHS structure and organisation form 10% of the AKT, and the SCA regularly tests knowledge of NHS processes (referrals, social prescribing, safeguarding pathways, prescribing governance).
🗺️ How the NHS is Structured — The GP's Position
The GP is the gatekeeper to the rest of the NHS. This means you refer, coordinate, and often manage without investigation — relying on clinical judgement far more than in hospital medicine.
| Concept | What it means | Why it matters in training |
|---|---|---|
| NHS (National Health Service) | Free at point of use, taxpayer-funded healthcare for all UK residents | Core ethical and organisational framework — AKT tested |
| ICB (Integrated Care Board) | Replaced CCGs in 2022 — plan and commission NHS services regionally | Organisational questions — AKT |
| PCN (Primary Care Network) | Groups of practices working together, with ARRS staff (physios, social prescribers, etc.) | Know what ARRS roles can do — AKT & SCA |
| Referral (Choose and Book) | GPs refer using NHS e-Referral system — patient chooses provider | SCA: correct referral pathway, 2-week wait (2WW) awareness |
| Fit Note / Sick Note | Statement of Fitness for Work — GPs issue, not hospitals in most cases | Organisational AKT question; common in real practice |
| Social Prescribing | Connecting patients to non-clinical support (groups, volunteering, arts) | Increasingly tested — holistic approach to management |
| Safeguarding | Protecting children and vulnerable adults from abuse or neglect | Essential — appears in SCA cases; AKT organisational questions |
| Controlled Drugs Prescribing | Strict legal requirements for schedule 2 & 3 drugs (morphine, temazepam) | AKT organisational questions — regularly tested, regularly failed |
🎙️ From the Trenches — Trainee Experience & Insider Wisdom
Drawn from the real experiences of doctors who have been through it. Patterns that appear repeatedly across trainee accounts, UK deanery resources, and GP educator guidance.
Why this section exists
Official guidance tells you what to do. Trainee experience tells you what actually happens. The most valuable advice often lives at the intersection of the two. Everything in this section has been cross-checked against RCGP guidance and GP educator teaching — it adds insight to what the official sources say, not alternatives to them.
📊 How IMGs Typically Prepare vs How They Should Prepare
A recurring pattern seen in trainee accounts of SCA and AKT preparation — and what the evidence says should shift.
❌ What Many IMGs Actually Do
Heavy on passive learning, light on active practice
✅ What Trainers & Exam Evidence Recommend
More doing, more feedback, more real patients
🗓️ AKT Preparation Timeline — What Trainees Who Passed Say Worked
🔥 AKT — Trainee Tips That Repeatedly Come Up
Clear AKT in ST2, not ST3
Repeatedly shared by trainees who passed first time: sit the AKT in ST2. ST3 is loaded with SCA preparation, ARCP requirements, and a full GP post. Clearing the AKT in ST2 frees you to focus completely on consultation skills in ST3. Book your exam date at the very start of ST2 — it creates structure and stops you drifting.
Stats and Admin need their own revision block
Many trainees who failed their first AKT attempted by a small margin report a similar pattern: strong on clinical, low on statistics and admin. The fix is simple but requires deliberate action: treat the 20% as a separate subject and allocate dedicated revision time. The RCGP data interpretation resource (free on the RCGP website) is excellent. One focused day per section is often enough to transform your score in these areas.
Do at least two timed mock exams
Time management in the AKT is a real issue for many IMGs — particularly when reading under pressure in a second language adds processing time. Trainees consistently recommend doing full timed mocks (all 160 questions in 2 hours 40 minutes (from October 2025; the format before this was 200 questions in 190 minutes — be aware if your sitting is before October 2025)) before the real exam. Do them under proper exam conditions — no music, no food, morning timing if your exam is in the morning. Familiarity with the time pressure removes one layer of stress on exam day.
In the exam: do clinical questions first, flag stats
A practical tip from trainees: if you're running short on time in the exam, tackle the clinical knowledge questions first (they're the majority and you're more confident on them), flag the statistics questions, and come back to them. Never leave any question unanswered — there is no negative marking. An educated guess on a statistics question is still a chance at a mark. And don't panic if you lose time — most people find the second half faster once they're in flow.
The day before: memorise these 4 things
Consistent advice from trainees about what to cram the evening before the AKT: (1) DVLA reporting rules — which conditions must be reported, and whether the patient must inform DVLA or you do; (2) Fitness to fly guidelines — common conditions with air travel restrictions; (3) Common dermatology images — use PCDS or DermNet; (4) Key drug contraindications and interactions from the BNF. These appear frequently and are easy to revise in a focused 2-hour block.
A study partner beats a study group
Many trainees describe their study groups as chaotic and unfocused. For the AKT specifically, a one-to-one study partnership — ideally with someone at a similar stage — is often more productive. You teach each other, ask each other questions, and hold each other accountable without the distraction of group dynamics. Trainees also recommend using RCGP GP SelfTest as a shared revision resource — you can compare answers and discuss explanations together.
🗓️ SCA Preparation Timeline — From ST1 to the Exam
🤝 SCA Study Groups — The Most Important Decision You Make
⚠️ The "Blind Leading the Blind" Problem
One of the most consistently repeated themes from trainee accounts — and one of the most underappreciated reasons why IMGs fail the SCA multiple times — is the composition of the study group.
When a group of trainees who have all failed the SCA practise exclusively together, without any experienced external input, a dangerous pattern emerges: they reinforce each other's mistakes. Each practise case feels productive. Feedback is exchanged. Cases are discussed. But the habits that failed them in the exam continue to be practised — because nobody in the group knows what a passing consultation actually looks and feels like.
Signs your study group has this problem
- Everyone in the group has failed at least once
- Nobody has direct experience of passing the SCA
- Consultations "feel good" during practice but scores don't improve
- Feedback focuses on facts ("you forgot to mention X") rather than consultation style
- The group meets frequently but each person's approach stays the same
How to fix it
- Include at least one member who has passed the SCA (or ask them to occasionally join)
- Include British-born trainees — their cultural intuition about consultation norms is genuinely valuable for IMGs
- Seek a trainer, TPD, or experienced SCA educator to observe and give feedback periodically
- Use the RCGP RAG (Red-Amber-Green) toolkit as a structured marking guide
- Record sessions — watch them back. You will notice things you don't notice in the moment.
⏱️ The 6+6 Rule — Time Management in the SCA
Consistently recommended by GP examiners and deanery educators — and confirmed by trainee experience as genuinely effective.
Aim to transition to management by the 6-minute mark. Clinical Management (CM&C) carries the highest mark weighting in the SCA — leaving only 2–3 minutes for it is one of the most common reasons for failing. Many IMGs spend 9 minutes gathering data and 3 minutes on management. This needs to reverse if you have this habit.
📋 The 8-Point Consultation Strategy
Write this on your whiteboard at the start of the SCA. Keep it in your peripheral vision throughout.
- Golden 2 minutes — open question, active listening, let them talk
- ICE — ideas, concerns, expectations
- Red flags — screen specifically for this presentation
- Additional questions — psychosocial context, driving if relevant
- Explain differential/diagnosis — chunk and check
- Management — options, shared decision-making
- Follow-up/safety netting — specific, tailored
- Close — "Any questions?" "Is there anything else?"
Not all 8 points are needed in every case — but having the structure written down prevents you freezing or losing your thread mid-consultation.
📅 On the Day of the SCA — What Trainees Wish They Had Known
Before the exam starts
- Set up your whiteboard in advance — write your 8-point structure
- Place a silent countdown timer at eye level next to the monitor
- Have a second (A3) whiteboard for jotting key patient information during the consultation
- Test your camera and audio thoroughly before the invigilator arrives
- The BNF can be used in the 3-minute reading time before each case — have it open
- There will be 9 video and approximately 3 audio cases — prepare for both formats
During the exam
- In the 3-minute reading gap: read the notes twice — once for facts, once for context. Write key points on the A3 board.
- Not every case needs smoking/alcohol history — ask only where genuinely clinically relevant
- Compartmentalise after each case. A bad case is one out of twelve. The next examiner has not seen the previous one.
- Aim to finish each case within 10–11 minutes — leaving 1–2 minutes for an unhurried close and agenda check
- The exam is long — 12 cases with short gaps — each lasting 12 minutes, with 3 minutes of reading time before each case. Get used to consulting 12 times back-to-back in a session during your preparation
Note on the quarantine period
If you are in the morning session, you will be quarantined for up to an hour after finishing while the afternoon session is underway. This can be unexpectedly stressful — plan for it. Bring something calming to do during that time. Don't use it to obsess over how the exam went.
😰 If You Fail the SCA — What to Do Next
Failing the SCA is distressing. Trainee accounts describe nightmares, self-doubt, and significant mental health impact. These experiences are real and valid. But they are also recoverable.
What NOT to do after failing
- Don't immediately join a study group of other people who have also failed — unless it has expert input
- Don't just do more of the same preparation — analyse specifically what went wrong
- Don't wait too long before seeking support from your trainer or TPD
- Don't try to change your entire consultation style all at once — work on one specific thing per week
What to do after failing
- Get your SCA feedback report — read it carefully and identify specific domain patterns
- Talk to your TPD/trainer — NHSE has support pathways specifically for SCA resitters
- Seek 1:1 coaching or expert feedback — the single most transformative change for trainees who have been practising in failing study groups
- Use the RCGP RAG tool to self-assess each practise case systematically
- Increase real patient consultations with videoing and trainer review
▶️ YouTube & Online Resources — UK GP Training Focused
Only channels and resources with a genuine UK GP training focus, recommended by deaneries or widely used across multiple schemes.
🎬 Recommended for SCA Consultation Skills
📚 Free Online Tools Trainees Rate Highly
🌊 The Seven Seas an IMG Has to Cross
A framework developed by Dr Isaac Frank (Severn Deanery) — reflecting on the cumulative challenge of UK GP training as an IMG. Each "sea" represents a domain where adaptation is required. Most IMGs can navigate several well; the SCA and AKT failures typically cluster around the ones in red.
Adapted from a concept by Dr Isaac Frank, Severn Deanery. Red = highest impact on differential attainment. Amber = important but more variable. Green = IMGs typically navigate well.
🔥 AKT Guide for IMGs — Where You Fail and How to Fix It
The clinical knowledge is usually there. It's the 20% that most IMGs don't prepare for that tips the balance.
📋 AKT Format (From October 2025)
The hidden maths
If you score 80% on clinical questions but only 45% on EBM and Organisation, you may fail the whole exam. Those 32 questions represent 20% of your total mark. Many IMGs score 70%+ on clinical questions but fail the AKT because they scored in the 40s on EBM and Organisation. Treat these sections as free marks — because with the right preparation, they are.
📊 Where IMGs Fail — Evidence-Based Practice & Statistics
Why IMGs fail this section
Statistics and EBM are often not formally taught in undergraduate medical schools in many countries. The concepts feel academic and removed from clinical practice. Research interviews with IMGs confirm this directly: "As an undergraduate I never went through statistics — no!" This is not a failure of intelligence. It is a gap in prior education that must be deliberately filled.
🎯 What This Section Tests
| Topic | What You Need to Know | Common Trap |
|---|---|---|
| Sensitivity & Specificity | Sensitivity = how well the test detects disease. Specificity = how well it rules it out. SnNout (Sensitive test, Negative result = rules Out). SpPin (Specific test, Positive result = rules In). | Confusing the two. Practice until automatic. |
| PPV & NPV | Depends on disease prevalence — changes with background rate. Low prevalence = lower PPV even with high specificity. | Forgetting that PPV/NPV change with prevalence; sensitivity/specificity do not. |
| NNT (Number Needed to Treat) | NNT = 1 / ARR (Absolute Risk Reduction). Lower NNT = more effective treatment. | Confusing NNT with NNH (Number Needed to Harm). Also confusing absolute vs relative risk reduction. |
| Relative vs Absolute Risk | Relative risk reduction (RRR) sounds impressive; absolute risk reduction (ARR) tells the real story. | Quoting RRR when ARR is what matters for shared decision-making. |
| Confidence Intervals (CI) | If the CI crosses 1 (for OR/RR) or 0 (for ARR), the result is not statistically significant. | Missing that a CI of 0.8–1.3 for a relative risk means the result is non-significant. |
| P values | P<0.05 = statistically significant (by convention). Does NOT mean clinically significant. | Thinking P<0.05 always means the result matters clinically. |
| Likelihood Ratios | LR+ >10 or LR− <0.1 have large diagnostic impact. LR between 0.5–2 = little impact. | Not knowing what LR values are clinically meaningful. |
| Study types | RCT > Cohort > Case-control > Cross-sectional > Case report (evidence hierarchy). Meta-analysis sits at the top. | Confusing cohort and case-control designs. Forgetting that RCTs establish causation; cohort studies show association. |
How to plug this gap
Dedicate 2–3 hours specifically to statistics revision. Use the RCGP data interpretation resource (free on their website — "Data interpretation in the AKT" PDF). Professor Michael Harris's videos on the RCGP site are excellent. Do 20–30 EBM-specific questions per week from a question bank. This section rewards systematic learning rapidly — most of it can be mastered in 2–3 weeks of focused effort.
🏥 Where IMGs Fail — Organisation & Management Questions
Why IMGs fail this section
These questions test knowledge that UK graduates absorb passively — through growing up in the UK, watching the news, having family members use the NHS, understanding benefits systems, knowing about GMC registration culture. IMGs have to learn this explicitly. Research shows IMGs face significantly higher odds of failing administration-based questions compared to clinical ones. The good news: this is entirely learnable content.
🗺️ High-Yield Organisational Topics for AKT
GMC & Ethical Duties
- Confidentiality — when to break it (safeguarding, DVLA, courts)
- Capacity assessment — Mental Capacity Act 2005
- Consent — adults, children, Gillick competence
- Duty of Candour — when must you disclose errors?
- Raising concerns — who to contact and when
Prescribing Governance
- Controlled Drugs — Schedules 2, 3, 4, 5; prescription requirements
- Yellow card scheme — when to report adverse drug reactions
- Shared care protocols — what GPs can and can't prescribe
- Patient group directions (PGDs)
NHS Processes & Administration
- Fit notes — what can be stated, when to issue
- Referral routes — 2-week wait (2WW) criteria by cancer site
- NHS e-Referral system (Choose and Book)
- GP contract requirements (QOF, DES, LES)
- Complaint handling — NHS complaints procedure
Safeguarding & Legal
- Safeguarding children — Section 47 (child protection), Section 17 (child in need)
- Safeguarding adults — Care Act 2014
- DVLA reporting — which conditions must be reported
- Death certification — who can certify, coroner referrals
- Court reports and expert witness duties
How to plug this gap
Read Good Medical Practice 2024 (GMC) — cover to cover. It is short and it answers many organisational questions directly. Study the RCGP curriculum section on Organisation, Management and Leadership. Use a question bank and track which topics you get wrong — you'll find patterns quickly. Many IMGs who failed their first AKT by a small margin improved dramatically on the second attempt by focusing specifically on this 20%.
🔥 AKT High-Yield Quick Facts for IMGs
📊 Statistics Cheat Sheet
- NNT = 1 ÷ ARR
- SnNout — Sensitive test, Negative = rules Out
- SpPin — Specific test, Positive = rules In
- CI crosses 1 (or 0) → NOT significant
- P < 0.05 = statistically significant only
- Prevalence changes PPV/NPV, not sensitivity/specificity
- LR+ > 10 = large shift in probability
- LR− < 0.1 = large shift downward
- Meta-analysis > Systematic review > RCT > Cohort > Case-control > Cross-sectional > Case report
🚨 Common AKT Traps for IMGs
- Confusing relative with absolute risk reduction
- Not knowing what schedule a controlled drug is on
- Forgetting Gillick competence thresholds for under-16s
- Missing that Fraser guidelines apply to contraception specifically
- Not knowing when DVLA reporting is mandatory vs advisory
- Confusing Section 47 (child protection) with Section 17 (child in need)
- Not knowing the 2WW referral criteria for common cancers
- Forgetting QOF exists — it drives a huge amount of GP workload
- Getting Yellow Card scheme criteria wrong — for new (▼ black triangle) medicines: report ALL suspected reactions; for established medicines: report SERIOUS suspected reactions only. "Serious" = fatal, life-threatening, disabling, requires hospitalisation, or congenitally abnormal
🎯 SCA Guide for IMGs — Where You Fail and How to Fix It
The data gathering is usually fine. It's the clinical management and how you relate to the patient that cost the marks.
📋 SCA: The Three Marking Domains
💊 Where IMGs Fail — Clinical Management Domain
The core problem in Clinical Management
The management plan is correct — but it is generic. It's what you would tell any patient with this condition, not this patient, with this life, this job, these concerns, and these preferences. UK GP expects management to be tailored to the individual. The examiner is looking for shared decision-making, patient-centred options, and plans that incorporate what you have learned about the patient's context. A correct but generic plan scores poorly.
| What IMGs commonly do | What examiners want to see |
|---|---|
| "I'd like to start you on [medication X] as per NICE guidelines." | "We have a couple of options here — let me explain them and see what suits your situation best." |
| Listing the complete management plan without checking the patient's preferences | Presenting key options, pausing, and asking "What are your thoughts on that?" |
| Safety-netting at the end as a routine final sentence | Tailored safety-netting based on what you've learned about this specific patient's circumstances and concerns |
| Correct diagnosis, correct treatment, but no follow-up plan | Specific follow-up timeframe, review trigger, clear plan for what to do if things change |
| Treating every case as a clinical problem to solve | Addressing the clinical problem AND the psychological and social context you've gathered |
| Not acknowledging the patient's ideas about management | "You mentioned earlier you were worried about taking medication long-term — let me address that specifically." |
The fix: Connect your management to the patient's story
Before giving your management plan, review what you know about the patient's ICE — their ideas, concerns, and expectations. Your plan must explicitly address at least one element of their individual context. "Given that you work night shifts, I'd suggest taking this in the morning rather than evening." "Because you're worried about side effects, let me explain what's actually likely to happen." This is what turns a correct answer into a passing one.
🤝 Where IMGs Fail — Relating to Others (RTA) Domain
The core problem in Relating to Others
The consultation is happening — questions are being asked, information is being gathered — but the patient doesn't feel heard. Empathic responses are absent or formulaic. The pace is too fast. There is no space given for the patient to respond emotionally. The consultation feels clinical but not human. This is often the result of consulting in a way that is entirely appropriate in another healthcare culture — efficient, accurate, and competent — but misaligned with the warmth and partnership that UK GP expects.
The 5 Most Common RTA Failures for IMGs
- Skipping empathy to get to the plan. Patient says something emotionally significant ("I've been really struggling since my mum died"). IMG moves straight to the next clinical question without acknowledging what was said. This is a clear RTA fail.
- Not exploring ICE. Never asking what the patient thinks is going on, what worries them most, or what they were hoping for. The examiner is watching for this specifically — it is often the single most powerful action in a consultation.
- Closed questions only. "Do you have chest pain? Do you get breathless? Any cough?" builds a clinical picture but not a relationship. Open questions and active listening change the whole dynamic.
- Speaking too quickly or formally. Under exam pressure, many IMGs default to rapid, doctor-led questioning. This feels efficient but fails the relational domain. Slow down. Allow silences. Give the patient space.
- Not handling the emotional moment. When a patient becomes tearful, upset, or angry — the instinct is often to push through clinically. The correct response is to stop, acknowledge the emotion, and give space. "Take your time — I can see this is really difficult for you." This alone can transform a failing consultation.
✅ What Good SCA Performance Looks Like for an IMG
High-scoring behaviours
- Open question to start — let the patient speak first
- Active listening — nodding, mirroring, brief verbal affirmation
- ICE explored mid-consultation — not as a tick-box at the start
- Empathy expressed genuinely — not scripted
- Management plan presented as options, not instructions
- Patient explicitly involved in the decision
- Explanation addresses the patient's specific concern
- Tailored, named safety-netting — not generic
- Agenda checking at the end — "Is there anything else?"
Common marks-losing behaviours
- Launching into closed questioning immediately
- Not pausing after the patient says something emotional
- Giving "the correct treatment" without involving the patient
- Generic, rushed safety-netting at the end
- Not checking the patient understands the plan
- Being factually correct but clinically robotic
- Missing hidden agenda — the real reason for attendance
- Consulting in "hospital medicine mode" — systematic, fast, directive
💬 SCA Consultation Phrases — Natural, Not Scripted
Phrases you can use tomorrow in clinic. Read them once; use them every day until they feel like your own.
The principle behind all of these
These phrases are not scripts — they are starting points. The goal is to internalise the structure, then adapt the wording to feel natural for you. A phrase that sounds slightly "off" when read from a list will feel much more natural once you have used it a dozen times in real consultations. Practise in clinic. Practise in role-play. The exam will feel like just another consultation.
🟢 Opening the Consultation
🟡 Exploring ICE — Ideas, Concerns, Expectations
🟠 Showing Empathy — Genuine, Not Formulaic
🔵 Explaining Clearly
🟣 Managing Uncertainty
🟤 Shared Decision-Making
🔴 Safety-Netting
🟢 Handling Difficult Moments
⬛ Closing
⚠️ Common Pitfalls — Trainee Traps
Things that catch people out. Read them now so you don't have to learn them the hard way.
🎯 AKT Pitfalls for IMGs
- Spending all revision time on clinical topics and almost none on statistics, EBM, or organisational content — then being surprised when they fail
- Not reading Good Medical Practice — this directly answers multiple organisational AKT questions
- Confusing relative risk reduction (sounds impressive) with absolute risk reduction (tells the real story)
- Not knowing UK-specific prescribing rules — controlled drug schedules, shared care protocols, and community prescribing expectations differ from many other countries
- Over-relying on clinical intuition for statistical questions rather than learning the formulas systematically
- Not practising with a timed mock — many IMGs run out of time because reading English under pressure is slower when it is not your first language
🎯 SCA Pitfalls for IMGs
- Consulting in "hospital doctor mode" — systematic, rapid, directive, doctor-led. This is entirely correct in hospital medicine. It scores poorly in the SCA.
- Never asking ICE. Proceeding straight to history, examination, management — missing the patient's own ideas and concerns entirely
- Correct plan, wrong style. The diagnosis is right, the treatment is right, but the patient was not involved and the examiner gives a Fail for both Clinical Management and Relating to Others
- Skipping emotional acknowledgement. The patient mentions something distressing; the IMG moves straight to the next question.
- Preparing only for the SCA in the last 2 months of ST3 training. The consultation style needs to become your default over months, not a performance learned in weeks
- Not keeping the FourteenFish ePortfolio up to date. WPBA is equally weighted with AKT and SCA in the overall MRCGP. Many IMGs fail at ARCP because of ePortfolio neglect, not exam failure.
The "one big course will fix it" myth
Going on a one-off SCA or consultation skills course is not going to fix consultation habits developed over years of clinical training. Targeted courses are useful — they are platforms that let you understand what good looks like and give you a starting framework. But unless you continue practising those skills every day in real consultations afterwards, the course will fade and the old habits will return. The fix is daily consistent practice over months — not a weekend course.
Nick Whelan's analogy — worth remembering
Nick Whelan, a former performance lead at Yorkshire & Humber Deanery, put it well: "You can't cross the road from halfway across — to do it well, or to survive the crossing, you have to get it right at the start." The consultation has to be built correctly from the opening — active listening, space for the patient, ICE explored early. If the first two minutes go wrong, the rest of the consultation rarely recovers.
💎 Insider Pearls — What Nobody Tells You at First
Drawn from trainee experience. The things people wish they had known earlier.
Your cultural background is a clinical asset
IMGs who have lived experience of different cultures can connect with patients from those backgrounds in ways that UK graduates cannot. Your multilingualism, your understanding of different health beliefs, your experience of different healthcare systems — these are genuine clinical strengths that benefit your patients. They don't appear in the exam marking domains, but they show up every day in real practice.
British patients understate. Always probe.
"A bit of a cough." "Some discomfort." "Not brilliant." British patients routinely understate symptoms, pain levels, and distress. What sounds mild in an English consultation might be severe by any objective measure. When a patient says they're "not great" or "a bit under the weather," gently probe further — you may find something significant underneath the understatement.
"Not prescribing" is a management decision too
Many IMGs from systems where prescribing equals competence feel uncomfortable leaving a consultation without a prescription. In UK GP, the decision not to prescribe — and to explain clearly why — is equally valid clinical management. The SCA specifically tests this. Safety-netting and watchful waiting score well when explained clearly.
Admitting you don't know builds trust in the UK
In some cultures, doctors are expected to project certainty — admitting uncertainty can feel like loss of face. In UK general practice, saying "I'm not sure yet, and here's what I'd like to do to find out" is seen as professional honesty. Patients and examiners trust it. Practise saying it until it feels natural.
The FourteenFish ePortfolio matters as much as the exams
Many IMGs focus almost all their preparation on AKT and SCA while neglecting their ePortfolio entries on FourteenFish. WPBA is equally weighted in the MRCGP. Trainees have failed their ARCP review — and been unable to progress — despite strong exam results, because their ePortfolio was poorly completed. Keep it up to date throughout training, from ST1 onwards.
Role-play is your secret weapon
Role-play feels awkward for most people. It feels especially awkward for many IMGs, who may find the exercise culturally unusual. But research consistently shows that role-play — particularly with a supervisor or peer providing immediate feedback — is the single most effective way to change consultation habits. Do it regularly. Start in ST1, not ST3.
🧠 The IMG Baseline Form — Use It Early
At the start of your GP training placement, ask your Educational Supervisor to complete an IMG Baseline Form with you. This is a structured needs assessment tool that helps your supervisor understand your cultural background, prior training, clinical skills, and language needs — so they can offer targeted support from day one, rather than trying to catch up later.
The form is in the Downloads section above. If your supervisor hasn't used it before, share it with them. It exists to help you.
👩🏫 For Trainers and TPDs
Use the RDMp Framework
When you notice your IMG trainee struggling, use the RDMp framework to diagnose the nature of the difficulty. Is it a knowledge gap (clinical or organisational)? A skill gap (consultation technique, clinical management)? An attitude issue (self-awareness, accepting feedback, professional culture)? Or a personal/circumstantial issue (isolation, family stress, language)? Different problems need different responses — and the framework prevents you applying the wrong intervention. The RDMp framework is available on the Bradford VTS trainee-in-difficulty page.
🌱 Start Early — Don't Wait for Failure
- If you spot difficulties at ST1/ST2, address them then — not at ST3. Early intervention is far more effective and far less stressful for both trainee and trainer.
- Don't assume "someone else will fix it later." If you see it, you own it.
- Complete the IMG Baseline Form at the start of every IMG placement — it structures your thinking and opens the right conversations.
- Build regular role-play into tutorials from the start. Even once a month is transformative over a 4-month post.
🤝 How to Build the Relationship
- Get to know them as a person, not just as a trainee. If you genuinely like them, you'll stay motivated to help them.
- Acknowledge the dual-task challenge explicitly. Naming the difficulty validates it and opens a more honest working relationship.
- Don't give the feedback "be more British." Give specific, behavioural feedback: "I noticed you moved on from the patient's emotional disclosure without acknowledging it — next time, try pausing and saying…"
- Balance individual support with peer learning. Find ways to introduce your IMG trainee to British-born colleagues and patients — this builds linguistic capital far faster than any tutorial.
Half-Day Release (HDR) — a powerful but underused opportunity
Half-day release sessions are most valuable when IMGs mix across different training stages and with UK-born colleagues — not when they sit only with other IMGs. That comfort is understandable, but it slows linguistic and cultural capital development. Peer learning works best when the peer group is diverse: different stages of training, different backgrounds, different comfort levels with UK consulting norms. One ST3 demonstrating a confident open consultation in a role-play is worth several tutorials. Gently engineer this mix in your HDR sessions.
💡 Tutorial Ideas — Specifically for IMGs
For consultation skills
- Role-play scenarios involving emotional complexity — tearful patient, angry patient, patient requesting inappropriate treatment
- Watch recorded consultations together and discuss what the GP said, how they said it, and what effect it had
- Practise "ICE in 60 seconds" — how to open a consultation and reach ICE quickly and naturally
- Watch British soap opera clips — discuss how characters communicate, interrupt, understate, and use humour
For AKT/organisational knowledge
- Dedicate one tutorial per month to a statistics/EBM topic — make it practical with real clinical examples
- Go through a controlled drug scenario together — what would you need on the prescription?
- Discuss a safeguarding scenario — when would you break confidentiality? Who would you call?
- Explain the NHS referral pathway for a specific condition — from GP referral to specialist appointment
On separate vs integrated teaching
There is a genuine tension between providing targeted IMG support and inadvertently stigmatising a group by separating them from their peers. Research suggests IMGs appreciate the insight and support of educators who understand their challenges — but that the risk of stigmatisation through over-separation is real. The ideal is blended: peer learning groups that include IMGs alongside UK-trained trainees, with individualised support provided through one-to-one tutorials and supervision rather than through separate group sessions that mark IMGs as a "deficit group."
❤️ Wellbeing, Support & Anti-Racism
You are not alone — and isolation is a real risk
A stark statistic — worth knowing
According to published GMC data, IMGs are approximately three times more likely to be referred to a fitness to practise (FtP) process by their employer than UK graduates. The GMC has explicitly committed to eliminating this disparity. This does not reflect clinical ability — it reflects systemic inequalities in how performance concerns are escalated. If you are an IMG experiencing workplace difficulties, seek support early: from your TPD, deanery wellbeing team, or a medical defence organisation (MDU, MPS, MDDUS).
Social isolation also directly affects linguistic capital development. If you spend all your non-work time with other IMGs — which is understandable, comfortable, and human — you reduce your exposure to UK cultural and linguistic norms. The solution is not to abandon your community, but to deliberately build additional connections with British-born colleagues, neighbours, and friends.
Seek peer support actively
Connect with other IMGs at your deanery and scheme. Online forums (including the IMG Connect and BAPIO networks) provide a space to share experiences, get advice, and find solidarity. Peer education — particularly with colleagues at different stages of training — is one of the most valuable learning tools available.
If you are struggling
Your deanery has wellbeing and counselling services — see the Support links in the Web Resources section above. The GMC's professional support unit is also available. Asking for help is not weakness — it is professional self-awareness. Your trainers and TPDs want you to succeed and are required to support you. Talk to them early rather than late.
🌈 A Note on Anti-Racism in Medical Education
The differential attainment gap between UK graduates and IMGs in the MRCGP is real and persistent. Research has identified multiple contributing factors — cultural, linguistic, systemic. But it also reflects a training environment that was not designed with IMGs in mind, and in which unconscious bias in feedback, supervision, and assessment cannot be excluded.
What helps — based on the evidence and experience of educators across the UK — includes:
- Celebrate diversity — bring different cultural perspectives into teaching, not just accommodate them
- Stop talking about "learner deficits" — frame challenges as systemic and contextual, not individual failings
- Focus on the trainer-trainee relationship — a trusted, respected relationship is the most powerful educational intervention
- Invest in educator development — on diversity, race, and unconscious bias, not just clinical skills
- Create inclusive work environments — where IMGs feel welcomed, not merely tolerated
🧠 Memory Aids — Cheat Sheet for IMGs
📊 Stats in 60 Seconds
🩺 The IMG SCA Checklist
🏥 IMG COMPASS Mnemonic — Navigating UK GP
| 🧭 | C — Culture — understand UK GP partnership culture first |
| 🔍 | O — Organisation — learn the NHS; it is AKT-tested and clinically essential |
| 🗣️ | M — Manage language — build linguistic capital through immersion, not just study |
| 📊 | P — Practise statistics — fill the EBM gap deliberately; it is learnable in weeks |
| 💬 | A — Ask ICE — every consultation, every time, until it is automatic |
| 📋 | S — Sort the ePortfolio — keep FourteenFish current throughout training |
| ⏰ | S — Start early — everything on this list takes months; ST1 is not too soon |
🗝️ ICE in Practice — The 3 Questions
Every consultation. Every time. These three questions change everything.
🏁 Final Take-Home Points
The bits to remember tomorrow.
- You are not failing because you lack ability. The gap is cultural, linguistic, and systemic — all of which are learnable. More than half of UK GP trainees are now IMGs. You are not the exception; you are the norm.
- For the AKT: Protect your 20%. Do not neglect statistics, EBM, and organisational questions. They are learnable in 2–3 focused weeks. Many IMGs fail the AKT by small margins solely because they didn't revise this section.
- For the SCA: Your clinical knowledge is likely fine. The failures are in Clinical Management (not tailored to the individual patient) and Relating to Others (empathy, ICE, shared decisions). These are consultation skills that must be practised daily — not techniques learned the week before the exam.
- Linguistic capital is built through immersion. TV soaps, British friends, English at home, reading UK fiction. Not through study alone. Invest in this every week.
- Learn the NHS. Not just its structure, but its values: free at point of use, patient autonomy, whole-person care, GP as coordinator and gatekeeper. These values underpin every AKT organisational question and every SCA case.
- Keep your FourteenFish ePortfolio up to date throughout training. WPBA matters as much as the exams. Many trainees regret neglecting it in ST1 and ST2.
- Start everything early. The skills on this page take months to develop. ST1 is the right time to begin. ST3 is not the time to discover you have gaps.
- Talk to your trainer and TPD. They are on your side. Early, honest conversations about what you find difficult are far more productive than waiting until things go wrong.
- Your cultural background is valuable. Your multilingualism, your lived experience of different health systems, your personal understanding of what it is to be a patient in a foreign system — these are clinical assets that enrich your practice and your patients' experiences.
"You crossed an ocean to become a doctor in a new country. The crossing is hard. But the view from the other side is worth it."
Bradford VTS — for trainees, trainers and TPDs everywhere
Some basics - how does the NHS in England work?
The NHS is a complex system, which can sometimes make it difficult to understand – especially working out who is responsible for what. It’s made up of a wide range of different organisations with different roles, responsibilities and specialities. These organisations provide a variety of services and support to patients and carers.
YouTube Video Lessons for IMGs
There are so many English Teachers on YouTube and below are some of my favourites. Please do have a look at their complete video playlists because it’s not just the English Language and its grammar that you need to know about. You Also need to get familiar with British culture, which in places, will be vastly different from your own.
Some of the best YouTube English teachers: (probably best to pick one that is British rather than American as you are working in the UK)
- YouTube: Learn English with Gill (excellent)
- YouTube: English Jade (excellent)
- YouTube: English with Ronnie (excellent)
- YouTube: EnglishSchoolOnline (good for pronunciation)
- YouTube ETJ English (good for pronunciation)
- YouTube: The English Coach
- YouTube: Grammar Girl (sometimes too theoretical)
- YouTube: EnglishClass101.com YouTube playlist
End Note - antiracism in medical education
- Celebrate diversity
- Stop talking about learner deficits
- Focus on trainer-trainee relationships
- Educator development – on diversity and race
- Draw on what we know helps
- inclusive work environment
- inspirational and supportive educators, mentors and peers
- regular and good quality feedback
