How to pass PLAB
Authors: Peter Cross
Publication date: 19 Jun 2004
Sabina Dosani and Peter Cross give the lowdown on the Professional and Linguistic Assessments Board test which non-European Economic Area doctors have to pass to be allowed to work in the United Kingdom. The authors interview examiners and candidates for their tips on passing
PLAB, the Professional and Linguistic Assessments Board test, is conducted by the General Medical Council and supported by the British Council, which organises and administrates PLAB part 1 exams outside the United Kingdom. The test is designed to assess overseas doctors' ability to work safely as senior house officers in a UK hospital and is a prerequisite for most overseas doctors' GMC registration. Every year, about 12 000 doctors sit PLAB.
Part 1 is a written paper, usually taken in the candidate's home country. Examiners expect doctors to have the breadth of knowledge needed to qualify from medical school supplemented by a year's experience as a preregistration house officer. Currently the paper consists of 200 extended matching questions.
Part 2 is an objective structured clinical examination. This tests clinical and communication skills in 14 stations. At each station you carry out a task. This may be talking to or examining a patient or demonstrating a procedure on an anatomical model—for example, suturing, phlebotomy, or resuscitating a dummy. You get an overall A, B, C, D, or E at each station. As long as you don't get a D at more than four stations or an E at two you will pass. There are 16 stations in total, but there is a rest station and a pilot station where new questions are tested. Marks from the pilot station do not count towards the exam. You must pass part 2 within two years of passing part 1.
The part 1 pass rate varies but is usually somewhere in excess of 60%. The pass rate for part 2 is around 70%.
How much does it cost?
Part 1 £145
Part 2 £430
Who writes the questions?
The GMC advertises for a panel of writers. Interested doctors are invited to a question writing day. They are taught how to write questions. Questions are written by a general practitioner with a surgeon, a psychiatrist with a paediatrician, and a physician with an obstetrician, to prevent them writing effete questions at specialist level. Questions are written in the morning, and in the afternoon the groups swap and check the style and format of the other groups' questions. If they don't understand the question, or think it too difficult, it is scrapped.
Examiners' and candidates' top tips for the OSCE
Introduce yourself and be courteous to patients.
Read or listen to instructions carefully.
Ask for permission before examining and explain the procedure, even if you are examining a dummy.
Offer patients choice. If you are asked to take blood, ask which arm they would prefer you to use. If you are required to give them information, establish what they know and ask if they have any questions.
Don't hurt your patient. For example, if the patient has abdominal pain, start palpating in an area that is not painful. If pain is unavoidable,—for example, when you are taking blood, warn the patient beforehand. Say something like, “Sharp pain coming now.”
Look first. There may be clues around like a hearing aid, asthma inhaler, or colour chart telling you what blood bottles to use.
Describe physical findings before giving a diagnosis.
Look the examiner in the eye. Speak confidently. Don't mumble or look at the floor.
Don't dwell on a bad station.
Thank patients and examiners at the end of each station.
Examiner's advice for part 1
Professor Kenneth Cochran advises candidates to work from general textbooks used by UK medical schools. “There are no hidden traps. People who become specialised find the exam hard because it is at the very general level of a recent medical graduate.
We ran a pilot on UK graduates coming to the end of their preregistration house officer year. We asked them about timing and appropriateness of questions. Those are the questions we are using now.
It's not obscure knowledge. It's more like, `a mother brings a child who has a rash.”
Examiner's advice for part 2
Dr Malcolm Campbell, chairman of the part 2 panel, says, “We are looking for basic clinical competence at the level of a first day senior house officer in any specialty. Candidates shoot themselves in the foot by rote learning and by going to these dreadful crammers. Many learn the right questions and don't listen to patients' answers. For example, the doctor says to a simulated patient `How are you feeling?' The simulated patient says `I think I'm going to kill myself,' and the doctor says: `And how are your bowels?'
“I would recommend people try to scrape together enough cash to spend a month in the United Kingdom, doing a clinical attachment. That would serve two purposes: they would learn how medicine is done in the United Kingdom, and improve their medical language skills making them confident.
Once you know the system you just fly through
“Our simulated patients are trained to behave like real ones. A lot of candidates are taken aback when patients ask questions like, `Why should I do this?' `What are the side effects of this?' `Is that the best course of action?' We are not saying that the way we interact is better, but that is the way that patients are dealt with in the United Kingdom.
“We don't expect candidates to be brilliant, rather the kind of doctor a consultant can trust to know their limitations, make basic diagnoses, and not harm too many patients. We are not looking for perfection. Everybody makes mistakes.”
Advice from candidates
Mohammad Amjad Khan sat PLAB part 1 in Pakistan: “I used several different study methods; studying on my own, in a group, and using past papers from the market. The hardest part was subspecialty EMQs on skin diseases, orthopaedics, and psychiatry. With the benefit of hindsight, I would not have relied on Indian EMQ books from the market as most of them were substandard and not clinically relevant.
“Stick to EMQ books written by UK authors such as Una Coles. If you can find a partner to study with, it is worth anything. I recommend the Medic Byte PLAB 1 Course (www.medicbyte.com) as well as the Pastest EMQs.”
You have to learn exam technique
Archana Mischra from north India is a paediatric senior house officer in Manchester. She passed PLAB part 2 and remembers, “Once you know the system you just fly through. But if you don't know how to approach it, or what you are expected to do you're sure to fail.”
A refugee surgeon from the Congo who preferred to remain anonymous feels, “In my country I spent a long time training in surgery and to pass PLAB you have to be good at everything, even things you read 10 years ago at medical school. Go back and learn them again. I go to a study group for refugee doctors at Queen Mary College, which teaches you how things are done in the United Kingdom, and that's what we need for part 2.”
GMC website PLAB page can be found at www.gmc-uk.org/global_sections/sitemap_frameset.htm (accessed 8 Feb 2004)
The medicbyte course can be found at www.medicbyte.com
Kroker P. PLAB part 1 EMQ pocket book: book 3. Knutsford: Pastest, 2002.
Collier J, Longmore M, Scally P. Oxford handbook of clinical specialties. Oxford: Oxford University Press, 2003.
Longmore JM, Hope RA, Longmore M, Wilkinson I, Torok E. Oxford handbook of clinical medicine. Oxford: Oxford University Press, 2001.
Kumar PJ, Clark ML. Clinical medicine. Saunders, 2002.
Ellis H, Calne RY. Lecture notes on general surgery. Oxford: Blackwell Science, 2003.
Campbell S, Lees C. Obstetrics by ten teachers. 17th ed. London: Hodder Arnold, 2000.
Clayton SG. Gynaecology by ten teachers. London: Arnold, 2004.
Coles U. PLAB: 1000 extended matching questions. London: Royal Society of Medicine Press, 2002.
*The resources mentioned in this article are not a complete list but those recommended by the candidates and examiners the authors interviewed for this article.
Otmane El Mezoued, a refugee general practitioner from Algeria, explains some of his difficulties with PLAB “In Algeria we had to write essays. In this country there are MCQs, EMQs, and OSCEs. You have to learn exam technique. I didn't pass PLAB 1 the first time. I thought books would be enough, but even if you are a genius and try to do PLAB without practising EMQs, you will fail. Go to any PLAB centre and wait for people who have just done the exam. Ask them when they come out where the study groups are. I joined a study group and passed.”
If you don't know the culture and how people react to bereavement, you will fail
Otmane also encountered some cultural difficulties with the OSCE: “For part 2 there may be a station on how to break bad news. If you don't know the culture and how people react to bereavement, you will fail. In the United Kingdom you involve patients in management decisions, and they have the right to know what is wrong with them. In Algeria, if a patient has cancer you talk to the family and they decide whether to tell the patient. The family make those decisions, not the clinician. Be careful with body language. If you come from a Mediterranean country you use more hand gestures, which UK patients might interpret as aggressive. I have problems controlling my hands. Now I clasp my hands together and interlink my fingers. Make yourself familiar with how UK hospitals run. What are the protocols? How do you take blood? How do you put a urinary catheter in? If you don't see how people do it in this country, you are in trouble.”
A refugee paediatrician from Afghanistan who also wished to remain anonymous describes his frustrations with PLAB: “I did a driving test here and passed on my fourth attempt. PLAB is like a driving test. It is about doing things in a certain way. I took PLAB so many times I gave up and just left it. I realised I was knocking at a closed door, but I had to keep on knocking. If you want to make it, keep knocking. I went back and sat it and passed.”
Essentials for PLAB part 2
Make sure you are competent at the following clinical skills: examining respiratory, cardiovascular, abdominal and neurological systems, examination of joints, vaginal examination including taking a cervical smear, funduscopy, taking blood, inserting an intravenous cannula, inserting a urinary catheter, inserting a nasogastic tube and checking its position on an x ray, blood pressure measurement.
Practise obtaining informed consent to common procedures. Be able to explain clinical conditions in layman's terms. You should be able to break bad news of a variety of conditions, including motor neurone disease, multiple sclerosis, and cancer.
Peter Cross freelance journalist