With international fellowships becoming more commonplace for gaining subspecialty experience, the authors describe the pros and cons of a UK fellowship and summarise the differences they have noticed in training and clinical practice between India and the UK.
Otorhinolaryngology, or ear, nose and throat (ENT), is a very specialised branch of surgery. There is complex anatomy stuffed into the tiny space of an ear, with a mesh network of nerves and vessels like a motherboard chip. Furthermore, the ear and nose act as a common corridor to the eyes and brain, and these sorts of factors attract many doctors to pursue this interesting career.
Getting started in ENT
Specialty training in India is called postgraduation. It is a three-year full-time course, usually in a tertiary care hospital. To be accepted onto a specialty training course, you need to obtain an ENT post. In 2022, the UK’s ‘competition ratio’ for ENT training, i.e. the number of applicants per available trainee position, was 3.6 while in India it was approximately 91. Of course once we enter medicine, you are student for life just as Cornard Hill said: “You are always a student, even as a master. You must keep moving forward.”
At the end of three years, candidates are awarded the degree of Master of Surgery (MS) or Diplomate of National Board (DNB) qualification. This is generally followed by a mandatory one year of an ‘acting up’ job where the new graduates can take up more responsibilities, including managerial roles, in addition to clinical work.
Figure 1. ENT Career Pathway India.
Depending on the further super specialty interest, the surgeon chooses between senior residency and fellowship, with an option of doing a three-year Master of Chirurgiae (MCh) (Figure 1). Therefore, most trainees undergo a total of three to six years of training in ENT including subspeciality after completing MBBS and foundation training. The training strictly follows the curriculum provided by the Medical Council of India for MS ENT or National Board of Examinations for DNB. Additionally, academic involvement is a must during training. Completing a dissertation or thesis, guided by senior staff, is mandatory for the trainee during their course.
At the end of the three years’ full-time training, a trainee is expected to have achieved competency in diagnosis, management, basic surgical skills and handling ENT emergencies. The trainee is then certified to practise as an independent general ENT surgeon.
Comparing working in the UK with India
When considering the workload differences between India and the UK, it is worth noting that India’s population is 1.4 billion versus the UK’s 67.33 million; this is a massive difference, and impacts on the number of patients seen per day. The spectrum of cases is different as well. For example, Betel leaf, ‘pan’ and tobacco consumption causes a lot of head and neck cancer, which is a significant chunk of the caseload in India. The huge patient load impacts largely on the clinical output. The long working hours, with saturated clinics of at least 50 patients per working day (which trainees undergo from the very start of their training) is a massive undertaking. However, eventually the competency is built in such a way that this is handled on a daily basis. One is trained to do 24-hours on call at least 10 days a month without any ‘post on call off’. Such a gruelling training, although not ideal, prepares the trainee to handle one of the busiest medical practices seen around the world.
Fellowship in the UK
Adaptability is the simple secret of survival and flourishing. The UK has been known for pioneering many ENT surgeries. Books like Scott Brown and Stell & Maran are recognised worldwide and are considered as standard textbooks. There are many other reasons that bring Indians and foreign nationals to pursue fellowships in UK:
- Work-life balance
- Dedicated subspeciality training
- Quality of life
- Holistic patient care
When an international medical graduate (IMG) chooses to move to the UK for future studies/work, there are many lucrative opportunities but he is faced with numerous difficulties.
Some of the challenges that an IMG faces include: adapting to the foreign healthcare system, the different patient pathway, the multidisciplinary approach, different protocols, and different guidelines. There is also the angst of living without one’s family and friends, as well as adapting to the different lifestyle and weather. These difficulties may be mitigated by the support of seniors, colleagues and the nursing team.
On the other hand, some main features that are striking about a UK fellowship are that there is personal attention given to you in the form of supervisors and mentorship, and there is a general absence of staff hierarchy. Every opinion is respected, the passion is supported, and bravery is encouraged. This instils confidence in the long term. In addition, there is also a good balance between clinical work, managerial activity, and academic involvement. Research and high-quality publications are always encouraged. Clinically, acting-up roles offer a taste of being a senior and help to train the fellow for future roles whilst also building confidence. Finally, the NHS system is very organised. The good networks of general practitioners (GPs) and other specialities help to optimise clinical management.
Settling down in any new place is a multifactorial decision. Moving to the UK has its benefits; the UK is the one of the top countries in terms of taking care of its workforce, with the best perks. Furthermore, the UK ranks 34th in Global Peace Index which assesses peacefulness of a country.
Additionally, in this current world, it is very important to take care of one’s mental health. The National Health Service (NHS) as a system is very supportive of this, and there is special consideration for needs such as childcare and disability. Indeed, having a weekend off gives us time to relax and catch up on other aspects of life, having time to travel brings joy and love back into our lives, and having easy access to beautiful places helps to rejuvenate our bodies, and enables us to bounce back with more positivity at work.
In conclusion, from personal experience we can say that working in the UK is a wonderful opportunity for those who want to specialise further and gain experience in a different medical setup, but it also means having to navigate personal challenges. Having said that, thanks to the medical community in the NHS, it is a fulfilling experience both personally and professionally.