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Doctors at Work Podcast.

Episode #69

How can we better support SAS doctors, locally-employed doctors, and international medical graduates? With Nitin Shrotri

Mat Daniel


International medical graduates form a large proportion of our workforce, with many working in SAS (specialty and specialist) or locally-employed roles. In this episode, Nitin and I discuss the challenges faced by international medical graduates, we talk about racism, and he tells me about the importance of nationally agreed contracts. All of us need to be open to diversity, and be aware of the prejudices and assumptions that we all inevitably hold. Talent doesn’t come with a British accent! A number of national initiative are taking place to better support international medical graduates and SAS and locally-employed doctors, and each one of us can also look at what we can do in our immediate environment. The charter for locally-employed doctors in the UK NHS can be accesses here.

Nitin Shrotri is a Consultant Urologist, who was awarded the BAUS Gold Medal for 2022, and has recently been appointed as Visiting Professor at the Institute of Medicine at the University of Bolton and also as Vice Chair at the Centre for Race Equality in Medicine. Before this he was BMA UK Council member between 2020-22 and a member of the GMC BME Forum last year. You can connect with Nitin on LinkedIn, and read his writings at

You can also watch at
Production: Shot by Polachek

Podcast Transcript

Mat: [00:00:00] Welcome to Doctors at Work. My name is Mat Daniel, and this podcast is about doctors’ careers. It’s part of my mission to help other doctors create successful and meaningful careers. Today, I’m having a conversation with Nitin Shrotri, and we’re talking about how we can better support SAS doctors, locally employed doctors and international medical graduates. International graduates form a large proportion of our workforce, with many working in SAS or locally employed roles.

In this episode, Nitin and I discuss the challenges faced by international graduates, and we talk about racism and he tells me about the importance of nationally agreed contracts. All of us need to be open to diversity And be aware of the prejudices and assumptions that we all inevitably hold. Talent doesn’t come with a British accent. A number of national initiatives are taking place to to support international medical graduates and SES and locally employed doctors, but each 1 of us can also look at what we can do in our own immediate environment. [00:01:00] Welcome, Nitin.

Tell me a little bit about yourself.

Nitin:  Good to see you, and thank you for inviting me here. Uh, so my name is Nitin Shrotri. I’m a consultant urologist.

Um, I’ve stopped clinical practice at the moment, uh, but I have just been appointed, uh, late last year as a visiting professor To the Institute of Medicine, uh, by the University of Bolton. Um, the job there involves me, uh, looking after International graduates who end up in trouble with the GMC and help them relocate or, you know, get back onto the pathway, uh, and and help support their careers. So that’s 1 of my roles, and it’s an important role. The second role That I have, uh, also been appointed to recently is I’m the co vice chair for the Center for Race Equality in Medicine, And that is where, again, we work with the [00:02:00] GMC to improve the situation for, uh, doctors coming from different places. So these are my 2 main roles, really.

Mat: And I know to today, I invited you to talk about SAS doctors and locally employed doctors, and I’m gonna come there in a minute. Um, but, actually, can I can you tell me a little bit more about those 2 roles that you’re doing as well? Because they sound really worthwhile, the both of those 2 roles.

Nitin: The reason for picking up these roles is that and I was invited to them. I’m really grateful for that.

It’s because, you You know, 40 percent of the UK workforce is made up of international medical graduates. And a lot of the SAS doctors, LED LE doctors, and TrustDoctors are all international medical graduates. Now trainees have people who support them, look after them, But the international graduates often have to fend for themselves and have to look after themselves, and they don’t get looked after. Not because [00:03:00] people always don’t want to, but often because people don’t know how to look after them and what can be done for them. So the system is is heavily against them.

And as a nation, we really need every doctor we have within the country to be looking after patients, uh, you know, Irrespective of where they come from. So that is the idea that, you know, we need to improve the quality of life And the support that we offer to these international medical graduates, and and that’s that’s my my aim. And both these roles will help me actually do that Better. Uh, the first 1 in a sense that IMGs end up in front of the GMC in trouble because of Some cultural issue, um, and and which they are not aware of and they don’t mean to be bad, but, you know, that’s how it comes across. And the second role is is also for similar reasons where, uh, you know, GMC data shows that, uh, Uh, international medical [00:04:00] graduates fare badly in many, many ways.

And the idea is to create a positive and constructive Society and place for work for doctors and also to make not just the profession, but also the general public aware of how we must treat our doctors, whatever they look like, whether they are black, brown, you know, or or or any other color, and and what accent they have. Because quite often, I’m nowadays seeing that accent is an issue that, you know, anybody who has a non British accent, gets immediately sort of, uh, out of favor in a sense. Uh, and that’s what we need to look at people and listen to what they’re so saying, not how they say. So that that’s my my role. Mhmm.


Mat: just maybe sticking with that point, but how how do we how do we change us as a profession and how do we change society then? What can we do? We all

Nitin: have [00:05:00] You know, what what’s familiar to us is always good for us. You know? We’re happy meeting people who look like us, who talk like us, who think like us.

And close our eyes perhaps and listen to what people are saying, not what they look like, not what their accent is like. Listen to the idea And how we can, you know, improve things, say, in the NHS because talent does not come just with a simple British accent. You know? Talent comes from everywhere. You know, every corner of the globe can offer us different ways of thinking, different styles of thinking, different ideas.

Britain used to be a very rich country, but we are not perhaps as rich as we used to be. And so perhaps there are nations who are poor who are seen as poorer nations, but who have good medical practices, which can be, uh, inculcated into the into UK practice, [00:06:00] into the UK way of thinking. And I remember Navina Evans, actually, who is the head of the, uh, you know, NHS workforce and training, um, area. She actually wrote an article on this about the UK learning from poorer countries. And what

Mat: what gets in the way of people having that open mind.

I I know that there’s a natural tendency that that, you know, we we we like what we know. We like people that are the same as us, and, you know, that’s that that that’s how humans are formed, isn’t it, you know, for revolutionary reason. But equally, probably most of us would would would say, actually, it’s really important that we have that diversity of views and diversity of opinion. So probably a lot of us know that, but what gets in the way of us of us practicing that?

Nitin: Basic human nature of prejudice, you know, which is we all have it in ourselves.

I mean, I I believe that I have prejudice within myself, but I have to work to become a better human being and look look beyond what I think. I think that’s the first thing. The [00:07:00] second thing is in the NHS, we are busy Firefighting. You know, we’re busy, uh, catching up what happened yesterday or last year, and we need to move faster, and think about today, uh, and and I think that will help. So a change in culture, a change in thinking, Opening our eyes, opening our mind.

I know these are all airy fairy things, but I think that’s the sort of thing that we need to do. And we need to Just listen and treat people better, really. You know? We treat should treat people as we want ourselves treated And keep our mind open to talent. So so that’s

Mat: that’s a, you know, that’s a mindset shift, and I’m always imagining, you know, There’s somebody on my shoulder that sort of says, you know, are you with these people because they like you?

Are you with these people because they’re any good? Yeah. Or, you know, have you appointed this person because they look like cue. You know, have you appointed this person because they’re really good at their job? And and and, you know, what you’re saying is [00:08:00] there’s a natural tendency.

I’m gonna want to appoint a person that’s like me because, you know, because that’s human nature. But what I need is to be aware of that little voice that sort of says, are you pointing to this person because they like you, or are you or are you giving them a job because they’re good at what they do?

Nitin: Okay. Tell me. Because that that’s a lot of people get threatened by good people.

Honestly. And and which is understandable again, But I think a lot of the time, you know, people in senior positions can feel threatened by appointing somebody who’s really smart because then they might take their jobs. So perhaps that is something we should also think of and be be more secure, perhaps. If we are more secure in ourselves, mission. Then then it’ll

Mat: help.

So that’s a focus on the bigger picture, isn’t it? That that, you know, we we’re here for the patients. I’m I’m building a team. I’m working with the team, and the purpose is the patient at the not not my career or my ego, but the [00:09:00] but the purpose is the patience that we’re trying to serve. Yeah.

Um, I’m interested in you you said with international graduates that that that we’ve we’ve created the system that doesn’t really give them support, um, that they need. So, um, if you were if I sort of say to you, you can create a new system completely from scratch, what what would you put into it?

Nitin: Oh, that that’s that’s that’s that’s a massive question. Um, you know, I I ran the I initiated the project, which was the SAS at Baus project, which is something that we’re gonna talk about today. And what it was, it started off with a new president being appointed to our organization, uh, who had an open mind, who was known to be a changer.

You know, he believed in change for the better. And somebody threw a question to him because he did a precedent [00:10:00] q and a, um, and somebody threw a question at him. What about SAS doctors? What can you do help them. And this is something I had on my mind because when I applied to be a GIRF, a lead for urology, 1 of my mission was to improve the life of the so called middle grade tier as they are called.

That’s a derogatory term I hasten to add because they don’t like being called a middle grade because they’re not middle grade because a lot of them are, you know, senior Specialist doctors. But that that was the aim that we need to reinvigorate that that tier. And That is something that I had in mind. And with that question being asked, um, the president, you know, ran with it. He accepted my idea, and, uh, you know, we flew from them.

Him and our vice president, who’s the first female president of of organization, Baus, um, they ran with it and supported it, and, you [00:11:00] know, it became a very supportive area. The idea there was to improve simply the morale of that group of doctors who had nobody to look after them, Or perhaps they can learn a particular skill in in in a niche area to give them that self esteem respect that they feel for themselves Or to go for CESR, c e s r, as we call it, uh, to to become consultants, full full full fledged consultants. And a lot of them really went for the Caesar pathway, and it’s important that we supported them. And we received support from the organization. And I think every specialty association should be doing that because, like I said earlier, we need all the medical workforce

Mat: and Bausse is British Association of Urological Surgeons for anybody, um, who’s, um, not from UK, [00:12:00] and and Caesar is an is an equivalence path to becoming a consultant.

Yeah. Or, again, for anybody who’s not in UK thinking what are they talking about. Um, so who who who is this group then? Let let’s talk about language because because we’ve because we we’ve used the term middle grade and, you know, that that’s a derogatory term, and then SAS locally employed doctors, trust great doctors. What what do these terms mean, and who is this group of

Nitin: doctors?

The first group of, uh, That we mentioned are the SAs, which is the specialty doctors, associate specialists, and specialist doc specialty doctors. And a new 1 came out a few years ago. Um, that is 1 of the good contracts for, uh, this group of doctors. But a lot of the other contracts, like the locally employed contracts or trust doctor contracts, [00:13:00] they are all variable in their terms and conditions. And these other contracts, they can have a variety of names.

They can be a senior SHO, a research registrar, a trust grade register, a trust grade doctor. You know, they can have um team names. You can pull any word out of out of your hat and and create a name for that But all these other contracts are prone to, uh, being misused. I’m not saying everybody does, but it’s very Possible that people could misuse and pay people, uh, which is something that is less than appropriate for their grade of experience. And I think it would help if everybody was on a national contract like this.

It does mean money for the NHS, but it does mean that people’s rights are protected and people get paid appropriately for the the work that they do. So that would be the first thing that I would say that all this nomenclature should really Come down to everybody being a [00:14:00] consultant, uh, a trainee, or an SAS doctor.

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Nitin: show.

Mat: Mission. So the SAS contract as it is, that’s a nationally agreed contract, and everything else is a hot hotchpotch of of of contracts, and nobody knows what they are and whether they’re decent or not because there’s no there’s no nationally agreed terms and conditions.

That sounds

Nitin: problematic. That that is that is problematic. But, you know, financially, it benefits Foundation trusts to have their own terms and conditions for employing people, um, at at, you know, possible minimum

Mat: wage. [00:15:00] I suppose it benefits them today because, you know, because today I’m paying somebody better, but, um, I’d be guessing it doesn’t really benefit people in the long term because, you know, if we employ people today on bad terms and conditions while they’re gonna burn out and they’re gonna leave. They’re gonna leave my trust and they’re gonna go to your trust.

You know, if you pay them better, they’re gonna come to you, and and they’re gonna leave me. So it might help me today, but it probably won’t help me in the

Nitin: long term. I think when we treat people badly, they may accept it. But at some point, they will realize that they’ve been treated badly, and, you know, that’s not nice in so many ways. And, uh, you know, It it’ll come home to roost.

Those chickens will come home.

Mat: So how how how have we ended up with with a large group of doctors that that are all on contracts that that don’t have any standardization. I think I think

Nitin: that’s an old story, probably many many years old, but I think That was done when the NHS expanded, um, its workforce using international medical graduates and did not wish to [00:16:00] pay or, you know, found the freedom of being able to work as independent foundation trusts and employ people as they wish to. Uh, That that’s something that I I don’t know enough about to really, uh, go. But I think that that what that is what has happened that over a period of time, they’ve just been left to fend for themselves.

And because of the world getting to be a better place, I think these things are now coming out into the open. And that’s why, uh, democracy is is good because people can speak up for themselves. Whether those, uh, in power hear you or listen to you or not is different, but at least We can speak up. Yeah.

Mat: So now what I’m wondering, if if if if I if I were an an entrepreneurial, locally employed doctor, I’d Create a website of how much different hospitals pay and what kind of websites do they have.

And and and they they’d be like a a, um, um, I don’t know, a sort of a a a an online review sort of come to Nottingham. You know, they they pay more and give you an SBA session, You [00:17:00] know, sort of if you go to, you know, somewhere else, you know, that you you you do 10 clinical sessions and no admin time. So, Um, so, actually, I mean, this this it it it sounds like at least in the long term that this this is not gonna be good for for either doctors nor the hospitals.

Nitin: Well, I I did suggest, uh, a few years ago that I think the CQC should have, um, a star, given to trust for how they treat doctors. You know?

In fact, if trusts are racist or have an express you know? Then they should have a star, you know, taken away for that. So that should be an area of of, um, assessment by the CQC. Yeah.

Mat: Mission.

Um, so, you know, what what needs to change about all of those multiple different contracts? You know, you talked about a national contract. How how how how would you implement that, and what do we need to do to make that happen?

Nitin: Well, simply as we have, um, A standard contract for trainees [00:18:00] and a standard consultant contract. That’s the sort of contract that everybody should go on.

They should go on to the SAS contracts. Anybody who is not a trainee or anybody who is not a con consultant, um, should be on the SAS contract. So that would just simplify things And and make life just standard for everybody, fair for everybody in terms of payment, in terms of, um, the roles, You know, that that duty hours, uh, because a lot of international graduates who are locally employed doctors will be working, um, unacceptable hours perhaps, And that depends on every trust. Um, now, yes, some some doctors may wish to work that hard, but as, um, a locally employed doctor, they don’t get enough protection. Uh, and I think the BMA is doing a lot of work to to support people, uh, there.

Mat: It it it’s interesting because I’m trying to think, do do I know what kind of contracts all of [00:19:00] our doctors are on? And I’m gonna be honest, I don’t think that I do. Yeah. So, um, so I wonder how many people are there out there, you know, listening or not, who actually have no idea what what what contracts the doctors are on.

Nitin: I this this is not really your fault or anybody’s fault.

I think we I remember being a consultant on call on a Friday afternoon, and my manager phoning me to say, oh, 0, I’m sorry, but there’s nobody on call tonight or the weekend. And my thinking is no. As in no registrar or no, uh, f 2. And my thinking is, oh, please just get somebody. And that’s when I don’t think about, are they paying them enough?

Are they doing you know, are they working too hard? No. I just want somebody. So, you know, we all become desperate in times of really desperate need, uh, doctors and managers alike, you know, so it’s not really anybody’s fault there. The fault is that we haven’t got enough doctors in in the country, and we haven’t [00:20:00] trained enough people Over the last 2 decades, we haven’t expanded our, um, medical workforce training places, and that’s why we’re paying the price, you know, for for not training enough doctors.

Mat: But I guess what I can do and what other people can do on Monday, they can say, what contract are our doctors on. Yeah? Because, you know, I will ask that question on Monday. In fact, I’m gonna schedule an email today to go out on Monday morning. And you say, what what contract are our doctors

Nitin: on?

Well, you might not be very popular with your managers. You’ll be looking for your next job soon.

Mat: I’ve I’ve got I’ve got broad shoulders, Nathan. So, yeah,

Nitin: Yes. Well, we need to speak for those who are, you know, uh, under our under our care, so to say, pastoral care.

Mission. May may

Mat: maybe I’ll ask the doctors rather than our managers. That’s that’s what I’ll do. I’ll I’ll I’ll I’ll ask the doctors that I work with what contract they’re [00:21:00] on and what they think of it. So may maybe maybe that would be, um, that would be a starting point.

Yeah. Yeah. Okay. I’m I’m interested also, you know, you talked about your, um, role in in race equality, if I kind of come come back to that, um, in terms of the the the the the workplace interactions. Um, again, you know, we talked about what I as an individual needs to do and that I need to be checking myself and asking myself those questions.

But what what what what do we need to change in the system to make things better.

Nitin: I was a BMA at British Medical Association council member for a UK council member for just over 2 years, uh, between 20 20 and 20 22. During that time, I wrote, um, about 8 blogs, uh, which were published by the, uh, [00:22:00] BMA BMJ, and they are on a a website that I have created. It’s a very amateur website. It’s called netting shroffrey dot dot com just to make it easy.

Um, but I put them there, and I put my experiences there from the time I came to the UK And how we should improve the NHS and how we should treat people better. And perhaps reading those blogs is something that people could do that’ll that’ll give us an idea about how we can just become better and how I’m still hopeful that I think We as society are are much better than we were many years ago, uh, and people are becoming more More accepting, more open, more forgiving, accepting that we, as a nation, can’t supply everything for ourselves. So if we [00:23:00] can’t look have enough doctors and we’re getting doctors from abroad, then we need to treat them with respect and support them in settling in the UK. And the GMC has started doing good work in terms of induction For international graduates, which is a great start. Uh, but I if you’re a Twitter follower, then we have leaders like, you know, Bart Karr, and Rob Fleming.

Rob Fleming is an SAS doctor, um, and there are other bodies like BAPIO and VIDA, who along with the BMA, you know, suggest how we can treat people better. Uh, Papio came out with a a charter for locally employed doctors on how they can be treated better. So that’s something to look at as well. Okay.

Mat: Definitely.

And BAPIO is British Association of positions of Indian origin. Thank you, Matt. Thank you, Paul. Thank you. Just just sort of, like, again, for anybody listening.

Absolutely. Yeah. And my term bring bring us to a close then, Nitin. [00:24:00] What would be your top tips for doctors at work?

Nitin: My If you wanna support our doctors, really, especially SAS doctors to become consultants, really, then we need to improve our Department’s staffing levels, really.

Um, so, uh, we should really have adequate staffing numbers. Share the support of consultants, of managers. Uh, we also need to have doctors who are motivated, and have, you know, a sense of drive. So our SAS and LE doctors should also, you know, not be sitting on their, on the chairs, uh, comfortably, but they should also be on on the on the marks, you know, get set and go sort of thing. They should have that Driven attitude to improve their data.

Uh, we should also look at the skill requirements in different departments, and, uh, we should, you know, have a desire Genuine NHS service improvement and [00:25:00] the desire to support talented international medical graduates. What are the actions we can do actually is, uh, we should identify individuals who are interested in pursuing These pathways, like the Caesar pathway, uh, we should use network contracts because the new Caesar pathway wants experience from 3 units. So 1 way of managing that is with the new ICSs or the new networks, we should issue SAS doctors or IMGs, uh, with network contracts so that they can go and work in different hospitals within the same ICS And get their experience in 3 different departments so that they get, uh, assessed by different consultants. So it’s not sort of done within in house. So, uh, So, uh, network contracts is is a good idea.

Uh, SIS doctor should also spend time with trainees Because there is a lot that [00:26:00] trainees can learn from experienced SAS doctors, and it’s it’s of mutual benefit to both of them. So We should encourage interaction, and 1 group should not feel threatened by the other. It’s important that we all work together. In terms of operating times, you know, they should spend time with each other because they can learn from each other. And it will also help if there was an SAS or locally employed doctor rep on the regional STCs, the specialty training committees, because then, essayist doctors can know what’s happening in terms of training.

Uh, there should also be local DME support for Study leave and, you know, courses, etcetera. Um, and and, uh, there should be an annual ARCP, you know, annual review of of competence In terms of, uh, how they are progressing so that there is somebody who’s keeping an eye on on the doctor’s progress and offering support as needed. The last 2 things that I [00:27:00] would suggest is that just like JCST, the joint committee for surgical training, uh, has got a chair who oversees all the training for trainees in, say, surgical departments, and there’ll be similar people for medicine and and, uh, pediatrics and ops and Shiny. There should be a a co chair to this chair who looks after the interests of those who are not on a formal trading pathway because, otherwise, these doctors have to fend for themselves, and there is no 1 to speak up for them. And serendipitously, Only 2 days ago, I received an email from a consultant colleague saying, I’ve got this specialty doctor who needs help.

He’s did his exam Twice. Um, but he’s good. He’s intelligent. He’s hardworking, and I wanna help him. And, uh, normally, a trainee would have, uh, the PSU, the professional support unit, to go and and get advice on on how, you know, he can he [00:28:00] or she can can do better.

But There is nothing for SAS doctors. So having a cochair on the training committee, um, and having some sort of professional support units for for those who are not on a formal training pathway would help. Yeah. So An accent doesn’t come uh, good talent doesn’t come with just a Portuguese accent is my thinking. I know.

Mat: The talent. Thank you very much, Nitin.

Nitin: You’re very welcome, Mat.

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