Since Mr Amol Pandit first came to the UK to work in 1991, he has worn many different hats, both clinical and non-clinical, and has been compelled to help others – particularly international medical graduates.
Amol came to Wales “by accident”. Having qualified and trained in Mumbai, Amol was invited by a colleague at King’s College Hospital, London, to work as a registrar in hepatobiliary surgery under a sponsorship scheme. His interest shifted to urology, which meant stepping back into senior house officer roles while developing his expertise. He completed the Diplomate in Urology at University College Hospital, London.
When Amol tried to secure a senior registrar job, with a view to becoming a consultant, he confronted barriers as an International Medical Graduate (IMG). “It was not as straightforward as I thought it would be. There were more trainees than consultant jobs, and the system was not keen on promoting foreigners when local trainees were waiting to move up the chain,” says Amol. He highlights the social capital that UK graduates had in terms of contacts in medical education and training, and via internships. Despite having undertaken his diplomat in urology in London, preference was given to local trainees. Amol says: “It does still apply, and rightly so, because we spend a lot of money on undergraduate medical education, and if we don’t give them jobs, they will migrate.”
Amol drew on the encouragement of some supportive colleagues and persisted in his attempts to further his specialism. “You must find your own path. There is no structured path for international medical graduates,” he says. He attended urology meetings and flagged repeatedly that he was looking to advance his skills. “I kept on knocking on the door of my clinical lead saying, I have done all this basic surgery and I now want to do the next step. Can you give me the opportunity, or can you tell me who else to ask? You must keep asking. My view is that unless you ask you don’t get. And I continue to do that even today.”
Moving to Wales
Amol’s wife, an anaesthetist, heard of an opportunity for a urologist at Glangwili General Hospital in Carmarthen. Amol joined as an associate specialist with the expectation of staying for six months, to see how it went. He started to work independently with his own lists and clinics, and the six months turned into three years.
In 2007, urology cancer work moved to Swansea and Amol became an associate specialist with what is now Swansea Bay University Health Board. He recalls the very positive reception he received from colleagues in Swansea. “You’re one of us,” they said to him, which made him “more excited to do my best.” At the time, there were four urologists in the department; now there are nine. Amol joined the senior surgical on-call rota and adopted the title “Urologist”. Apart from a different pay scale, Amol insists there is no difference between his duties and those of his consultant colleagues.
Advocating for IMGs
Supporting doctors from Black, Asian and minority ethnic backgrounds is an important driver for Amol, who is a member of the Welsh council of the British Medical Association (BMA) and co-chair of BMA Welsh FREE (forum for racial and ethnic equality). He has been helping with the roll out of the Race Anti-racist Wales Action Plan. He is committed to helping IMG doctors integrate into NHS jobs by offering them advice and practical support, such as introducing them to churches or temples where they can find a sense of community. As faculty lead for trainees for his Health Board, Amol is keen to establish an undergraduate medical exchange programme between Swansea and Cardiff medical schools and the five medical colleges in Mumbai to enable UK trainees to gain training opportunities lost during the COVID-19 pandemic.
Amol highlights a range of issues that IMG doctors can face in the workplace. At the most basic level, this includes a lack of structure for information sharing. The Health Board has email mailing lists for consultants and SAS doctors, but no equivalent for IMGs participating in the Medical Training Initiative (MTI) – a UK scheme that allows a fixed number of IMGs to work and train in the NHS for up to 24 months. These are Locally Employed (LE) doctors; Amol refers to them as “locally exploited doctors”, because they tend to be put into roles where there are insufficient numbers of trainees, covering unpopular shifts (such as weekend nights) and without structures to offer them training or mentorship. “I keep fighting their corner and for employers to make opportunities available to these doctors and share information,” says Amol.
He highlights that IMG doctors often lack the confidence to speak up. He explains: “If they are unfamiliar with the system, they don’t know who to ask.” It is with this in mind that Amol gives voice to their concerns to the chief executive and medical director of the Health Board. “You need to give them what’s happening on the ground, not for yourself, but just for the department or for the team. They are often reluctant to speak out, either because they say I’ve said this before and nobody’s heard me, or there is a fear of punitive action being taken.”
SAS recognition
Amol observes that IMGs are over-represented amongst SAS doctors. One of the biggest issues faced by SAS doctors is a lack of recognition for the contributions they make. Amol says: “They literally hold the hands of trainees and help them with procedures, and yet the day those trainees get appointed as consultants, they treat these SAS doctors as superfluous to their requirements and will order them around. That culture needs to change and these doctors who have been working independently and have been training them should be recognised as trainers.”
Another example is the way SAS doctors from minority ethnic groups can be shut out of leadership opportunities. He says: “SAS minority ethnic doctors are not given opportunities to get into leadership roles or they are shortlisted but on the day the role is pulled because no consultants applied.” He also highlights unfairness with respect to waiting list initiative activity, which for a long period was not offered to SAS anaesthetists within his Health Board. This changed when consultant anaesthetists reduced their waiting list initiative work due to pension tax rules, allowing SAS doctors to fill the gap. “The decisions weren’t based on ability. Why else would SAS doctors be allowed to do work on weekdays but not the same work at weekends?”
Amol takes issue with the emphasis placed by medical royal colleges and others on post-graduate qualifications. “Having a number of alphabets after my name does not make me a better doctor. Having the skill to talk to a patient, address them appropriately, make sure that I know my limitations and what the best is that I can do for the patient, and that I’m technically skilled as a urologist, is what matters.” He adds: “I’ve spoken on these topics repeatedly in the last five years and everybody gives me lip service but no real tangible change on the ground. The way people are recognised makes a huge difference; it puts a smile on their face and encourages them to do more of what they are good at.”
Amol believes that healthcare organisations need to find ways to recognise the skills of the SAS workforce and place less emphasis on their grade as an SAS doctor. “I have always felt that a small thank you or a small well done goes a long, long way. It doesn’t have to be a big trophy at the end of every year,” he says. He advocates using monthly clinical governance meetings as an opportunity to highlight thank you letters from patients or feedback from colleagues.
Amol’s career journey
Medical Director perspective
Richard Evans, executive medical director of the Health Board understands the importance of recognition for this workforce. “The SAS doctor group is a very, very diverse group of medics that range from very junior, locally employed doctors at the earliest stages of their career, through to SAS doctors who’ve got more years under their belt than many of our consultant surgeons,” he says. “Our starting point in Swansea is recognising that this is a group that needs to be valued.”
The Health Board has appointed an SAS advocate, who is identifying the different constituencies under the SAS umbrella. Richard believes that the number of LE doctors has expanded the fastest, which he thinks reflects a greater proportion of junior doctors in less than full time training. “You might have ten names on a board, but in reality you’ve only got five or six people to work the rotas. It isn’t at all unusual to have all or most of the trainees working less than full time, and that’s where I think locally employed doctors come in.”
Richard argues that LE posts can be a useful springboard for these doctors. “In trauma and orthopaedics, where training posts are highly competitive, locally employed doctor posts are very attractive because it gives people the opportunity to work in the UK or get some experience under their belt for the next step.” Often, that next step is to get on a training programme, but Richard believes the system should think more expansively about SAS roles for LE doctors. He says: “we’re not proactive enough about saying to people who are locally employed, you don’t have to go on a training programme to progress. We can build up your skills as a specialty doctor and then support you to go down the CESR route.” This will involve shifting mindsets away from the traditional training pathway. “Ultimately, what we want is highly motivated, well trained excellent clinicians to stay with us in Swansea rather than to see them move elsewhere.”
The Health Board encourages its SAS and LE doctors to pursue the CESR route as a means of retaining the medical workforce. It runs in-house CESR rotations in emergency medicine and anaesthetics, and Richard believes more doctors would apply for CESR with the right support.
The key to unlocking the potential of SAS careers for Richard is to value the different choices that doctors make and avoid regarding some as inferior. “I’ve got a couple of friends who are SAS doctors and they’re really clear about why they’re doing it career wise because they don’t want what comes with being a consultant. They’re getting paid a salary that works for them, and it’s an attractive career in its own right. One of the brilliant things about medicine is the diversity of jobs that you can do.” He is keen for SAS doctors not to feel any shame about their job title and to avoid terminology that focuses on grade, for example, referring to the ‘senior medical or surgical on-call rota’, instead of the ‘consultant on-call rota’, and opening leadership positions to any senior doctor. “I think it’s about respecting individuals and their expertise rather than necessarily becoming overly focused on the grade.”
In terms of supporting IMG doctors, Richard says: We’ve done a few things and there’s more that we can do.” In addition to induction, practical steps include meeting a new doctor off the train, so they are not left to make their way to the hospital. The SAS Advocate is creating networks that new starters can tap into and there is a BAME (Black, Asian and minority ethnic) network. Richard shares an example of a Nigerian doctor who joined the Health Board as a junior clinical fellow and became very homesick. The BAME network linked the doctor to a local church with a community of people from Nigeria and this “absolutely transformed him” says Richard.
Richard sums up his approach to the SAS workforce in terms of “making people feel valued, appreciated and supported.” He says: A lot of it is about making sure that we’re having conversations with [SAS colleagues] and job planning meetings, and that they’re talking in their appraisals about their own career development. It’s an appreciation that they’ll have their own ambitions, whether that’s the CESR route, transitioning to the new specialist grade, or pursuing leadership or other opportunities.”
Advice on supporting IMGs
Amol’s tips on helping doctors from overseas settle into NHS jobs:
- Provide an induction package, which informs the new starter about life as a doctor in this country. “It’s different to the health systems that they were working in, so we need to give them good guidance on what to expect,” says Amol.
- Identify a buddy, for the first week or so, somebody from the department who the new doctor can tag along with, so they get to see how things work and the pattern of working. “Otherwise, it causes a lot of angst for the hospital if the doctor doesn’t do things right and anxiety for the new person because they didn’t know any different,” says Amol.
- Free them from on-call, releasing new doctors from overseas from on-call in the first week enables them to understand the layout of the hospital during the day, as well as the local area, and do things like open a bank accounts, settle into accommodation, check where the hospital cafeteria is situated, etc.
- Consider offering an educational supervisor, to provide support to IMGs.
- Create a community, set up an email or WhatsApp group to communicate with this group of doctors about, for example, lunchtime meetings or educational or social activity.
Paying it forward
“I get lots of messages from different people asking for different sorts of help, and my philosophy has always been if I can, I will help,” says Amol.
“I think that’s what I would like to be remembered for, that I always have time for everybody. Anybody who needs help, I will try and help. I may not always be able to help, but I will certainly try to.”
Advice on developing as a leader
Amol’s tips for SAS or LE doctors wanting to develop as leaders:
- Represent your peers, in your department or, if the department is not large enough, in your hospital division. “Be their voice and the person who represents their cause,” says Amol. “And once you have that, you are more likely to be engaged in conversations with the clinical leads, clinical directors, unit medical directors and then the next step from there would be the hospital medical director and associate medical directors.”
- Voice matters of collective concern, such as clinical issues, or rotas, annual and study leave, opportunities to participate in lists, etc.
- Increase the community of doctors you represent, “It’s a number game – you start out representing four doctors and soon you’ll be representing 4,000.”
- Seek a mentor, someone who has been in the system for a good amount of time and can help you to put yourself forward for roles.
How medical leaders can help
- Recognition: recognising the contribution of these doctors can make all the difference, says Amol
- Provide opportunities to progress: in terms of independent practice and also leadership roles
- Active encouragement: don’t wait for SAS or LE doctors to volunteer for leadership roles, ask them if they would like to be the next audit lead or clinical lead. “Put them on the spot and let them say no rather than wait for them to raise their hands,” says Amol. They may have volunteered in the past and nobody took them seriously.
