USMLE vs PLAB

So, you’re a doctor/medical student from a country other than the UK. You’ve either completed your MBBS or are about to, and now you want to go work in another country. For the vast, vast majority of you, that means making the following choice; should I do the USMLE, or should I do the PLAB?

For those who are unaware, the PLAB exam (Professional and Linguistics Assessment Board) is the medical licensing exam required for foreign doctors who want to work in the UK, and the USMLE is the US Medical Licensing Exam (thus the name). Undoubtedly, if you’re from countries like Pakistan, India, the UAE or those in North Africa, you will have hundreds of examples of seniors from your medical school who have pursued both the UK and the US route. This is nothing new. Even from my dad’s generation, his entire graduating class from Khyber Medical College in Pakistan would basically split into thirds between staying in Pakistan, going to the UK, or going to the US.

So, in our modern times, how should one approach making the decision of where to go and therefore which of these above exams to start studying for?

There is no ‘wrong’ answer

I think this is the first thing to realise. It’s natural for us as humans, and more specifically for us medical students/doctors, to want to logically weigh up all the factors and reach the ‘right’ answer - it’s what we’ve been trained to do! But, what we have to acknowledge right from the outset, is that there is no wrong answer. The question you are trying to answer is, “will I have a happier and more fulfilling life in the UK or in the US?” There are millions of different variables, life events, pure chance, that can make it so that your decision to live in either of these countries is a fantastic one or a horrible mistake. You will never be able to control all of these, so don’t paralyse yourself with endless hypotheticals. Likewise, once you have made the decision and picked one of these countries, you will still never know for sure whether you made the ‘right’ decision, because you’ll never know what the alternative in the other country would have been like!

Perhaps you decide to become a doctor in the UK, you meet the woman of your dreams during your ‘house job’, get married, have kids, one of whom goes on to become the Prime Minister of the UK. In that case, it sounds like a pretty good decision! But maybe you would have met someone better in the US… and your kids could’ve been the President… you clearly had good genes after all…?

You get my point. We can plan all we want, but life has its own plans for us, so once you make your decision, feel content with it and move on! You can have an incredible career and life in either of these countries.

Things to Consider

All of that being said, I’m not arguing that we all just flip a coin and then let the multiverse decide which branch of life we follow! It’s still down to us to consider some different aspects of medical careers in these two countries, and then try to make an educated conclusion of which fits our priorities better.

Salary

There’s no point being shy about this, we’re all friends here. Being a doctor, as much as it may be a calling, a passion, a purpose for us all - it’s also our job. The thing that is providing most of us our main source of income (we can’t all be YouTubers like Ali… ) So it is important that we address this head on.

I’ve written a more detailed blog on this site where I specifically break down the details and explain the Doctor Salary Differences in the UK and US, so check that out for a more deep dive. But for the purposes of this article, let’s just accept the below two headline facts.

  • The average Attending (“Consultant”) in the UK earns around $121,900 per year.
  • The average Attending in the US earns around $313,000.
  • The average time between finishing medical school in the UK to becoming an Attending is around 8 years.
  • The average time between finishing medical school in the US to becoming an Attending is around 4 years.

Before any of your Sherlocks out there start berating me, yes, there are exceptions to these values, which is why these are averages. The earnings of an Attending in the US vary greatly depending on the location of practice as well as specialty of choice. However, these ranges tend to go from $200,000 a year average to upwards of $500,000 a year. In no world, regardless of location or specialty, could you realistically say a doctor in the UK would generally make close to as much as a doctor in the US. A small amount of doctors in the UK can, very late on in their careers, have a ‘private practice’ established that can significantly supplement their NHS earnings listed above, but these are far from ‘normal’ examples of what life in the UK as a doctor would involve.

Similarly, the average time from graduation to becoming an Attending I’ve listed above also vary. Those who become General Practitioners in the UK become Attendings in 5 years, whereas those who do Neurosurgery training in the US take 7 years to become Attendings. However, on the whole, a like for like comparison of any specialty will show that the length of postgraduate training to become an Attending is shorter in the US.

This means that, on the whole, you are likely to earn more if you choose to practice in the US vs the UK, and you are likely to earn it earlier in your life.

Choice of Specialty

No matter what country you are applying to, getting training posts in fields such as dermatology, orthopedic surgery or plastic surgery will always be difficult. However, the barrier to entry for an IMG trying to match into one of these hypercompetitive specialties is even higher in the US as compared to the UK. Because of the way the system works in the UK, you  can often get ‘on the ladder’ at an early stage in either a ‘Foundation Year’ job or as a ‘Core Surgical or Medical Trainee’. These jobs involve rotating through various different fields within the UK healthcare system for a few years, before ultimately applying for a ‘Specialist’ trainee job. This may be annoying for some people who see it as an unnecessary prolonging of the training pathway, but as a foreign doctor, these early years give you the opportunity to build your own reputation and enhance your ability to compete with the ‘home grown’ doctors of the UK when it comes time to apply for specialty jobs. You are still at a disadvantage, but you may have had 2-3 years of time to become well-known by your colleagues, to strengthen your portfolio with achievements within the NHS, and therefore to be taken seriously in those future applications.

In the US, you go straight from medical school graduation to applying directly for these specialty training jobs as a ‘residency’. You therefore don’t have that same opportunity to become an ‘insider’, and could be dismissed for the majority of competitive residency programs just by virtue of being an IMG.

Now, as I cover in my blog post ‘How I Matched Into Dermatology as an IMG’, this is not an insurmountable task. We at LibertyMedics are here for that purpose! But, I do think it is worth bearing in mind that if your heart is completely set on a hypercompetitive specialty of medicine, you likely have a stronger chance of making that a reality in the UK compared to the US.

Attending (“Consultant”) Job Bottlenecks

Having said the above, regarding how it can be more difficult to get a training job of your preference in the US vs the UK if you are pursuing a ‘competitive’ specialty, it’s worth discussing the situation in each country at the end of your training posts. It feels like a long way off at this point, but it’s all about forward thinking - how hard is it to get Attending jobs in your area of expertise in the US vs the UK?

In this case, the situation is effectively reversed from the previous section. In the UK, there are notoriously few “Consultant” (Attending) jobs available throughout the country. Because there is effectively only one employer (the NHS), there are far more trained doctors being generated in the system than there are  available senior level Consultant positions. This is what is commonly referred to as the “Consultant Bottleneck” in the UK, where large numbers of doctors finish their specialty training, and reach the choke point of waiting around for a Consultant job to open up. This can take years, and often, trainees end up stuck at a perpetual senior training job, never reaching the Consultant status. Alternatively, they may be told that finally a Consultant Cardiology job has opened up, but it’s far away on the East Coast of England in Norwich. Doctors end up changing their entire life plans (children’s schools, spouse’s job etc.) to move for the precious few Consultant jobs that may become available.

What about in the US? The story could not be any more different. The level of flexibility when it comes to practice settings in the US means that, on average, any resident entering the final year of their training is likely to be fielding tens, if not hundreds, of Attending job offers ready for as soon as they become Board Certified. Granted, if you specifically want an Assistant Professor job at a large academic institution, you may still have to be patient. But, if you are willing to be flexible geographically and in terms of your practice setting (small rural hospital, large urban metropolitan hospital, multi-physician specialty practice etc.) you are effectively guaranteed to move straight into an Attending job at the end of your training.

Will The Healthcare Systems Change?

Speculating on and forecasting the structural changes in healthcare systems truly is a fool’s errand. Those who spend their lives as healthcare journalists are in a perpetual state of confusion and can’t give any firm opinions on how they think either the NHS or the US healthcare system will change. However… it’s sometimes fun to speculate, so let’s do some of that anyway!

“The NHS is going to go private” is a phrase familiar to any UK based medical students or doctors. It’s something that has been predicted for many decades, and some people will argue that certain political parties are trying their hardest to make this a reality. Do I think it will happen? Not really, no. The NHS is far too popular in the UK for any political party to take the risk of openly turning it into a private system. That would basically mean them losing every election for the next half-century, and it’s not something I anticipate any of them will risk outright. Could they, by choking off (or continuing to choke off) it’s funding, slowly make the system so overstretched, frustrating and unbearable to the public, that they could then justify making some aspects of healthcare private? Yes, maybe. But I don’t think that the NHS system will fundamentally change to a private insurance model such as we see in the US any time in the next few decades. (Conservative Party: “Hold my drink…” )

“Medicare For All, public health care, is coming to the United States”. Before the COVID19 pandemic took over the entire news and political coverage in the US, one of the biggest questions being discussed in the ‘race for the Presidency’ was whether or not the Democratic Party would officially come out and endorse a policy to move the healthcare system towards a more Government run direction. The nuances of this debate (a ‘Single Payer’ healthcare model vs a ‘Medicare Buy-In’ vs a ‘Public Option’ vs ‘Medicare For All’) are beyond the scope of this article (…maybe beyond the scope of ever putting on this page because I don’t know if anyone else is interested in my political deep dives!) However, do I think that the US healthcare system will undergo a complete revamp and become a public system? Not really, no. It’s hard to believe, as an outsider, that a country full of people would somehow recoil from the idea of their government guaranteeing them healthcare as a right. But that really is the situation here in the US. Americans have, on the whole, internalised the idea that government run programs are inefficient, lead to lower quality, and are easily abused. While there is certainly some truth to this, the message is exaggerated and blasted into the living rooms of millions across the country by motivated insurance, pharmaceutical and media executives. Sadly… propaganda works!

There may be a successful attempt to allow members of the public to choose a Government run insurance, rather than a private industry one, within the next 3-5 years. However, do I think this will be the first step on the way to a public healthcare system in the long run? Unlikely.

Political Climate

Again, whoever thinks they can reliably predict what any society will look like 10 years from now is deluding themselves. It’s natural for those from the outside to consider questions of politics/society such as; “How will Brexit affect my potential future in the UK?” or “Will the US even exist in 10 years if Donald Trump is reelected?” Both very fair questions. But in that same way, we have no idea what the political situations in the UAE, India, Pakistan, Columbia, Venezuela, Egypt etc. will be like in 10 years.

In the short-medium term, for doctors from around the world, we are lucky enough to be considered highly skilled workers. Almost any country in the world is happy to welcome extra doctors into their work force. The United States acknowledges that it needs tens of thousands of extra doctors in the country in the coming decades, a number they simply can’t reach using their own existing medical schools. Likewise, the NHS is perpetually understaffed and is more than happy to welcome an immigrant doctor work force for the foreseeable future. Also, the proposed ‘points based’ immigration system that even the most anti-immigration political parties in the UK and the US support, would likely end up favoring doctors from across the world and making it easier to come to and settle into these countries.

Bottom line: it’s hard to tell what will change, but we’re pretty lucky as doctors because we have a vital set of skills that even anti-immigration loyalists realise they need! There’s no clear cut answer as to which of the UK or the US will be “better” for you from a political perspective unfortunately!

Racism

It’s completely natural to wonder, as a soon to be ‘foreigner’ in either the UK or the US, how tolerant the respective societies are to immigrants. Your happiness in either of these countries won’t just depend on what it’s like at work, but also how comfortable you and your current (or future) family’s will be living in the country. The answer, for both the US and the UK, is: it depends where you are. Unfortunately, there is no denying that in both of these countries, recent political trends are such that less educated, less diverse, and often less densely populated rural parts of these countries have shown increased incidents of racial abuse/violence. That’s not to say it’s a hellscape for anyone with melanin in their skin; plenty of immigrants live in ALL parts of the US and the UK. But it is to say that, when deciding where you may feel the most comfortable settling long-term, it’s not so much a case of which of these countries, but where within each country you choose to settle. I can say, whole-heartedly, that having lived in Birmingham/London in the UK, and then New York City in the US, I have felt completely comfortable, welcome and truly like I belonged. I reject the idea that “America is racist” or “UK is racist”. There are racist people in both of these countries. But there are also incredibly kind, loving and open-hearted people. Just make sure you take the time to pick an area with more of the latter than the former. And remember - if a Pakistani-born, Muslim immigrant named Usama Mohammad Syed, with a beard, can move to the US successfully and not have any problems, you’re probably going to be OK…

Education Systems

I know what you’re thinking - relax Usama! I’m in my 20s, just trying to decide which exam I should study for, and you’re telling me about education systems for my theoretical future kids! Hey, I told you guys before. At LibertyMedics, we pride ourselves on the attention to detail. Anyone can tell you ‘doctors make more in the US than the UK but the exams are harder’. We’re here to help you think about paying for your kids’ future medical degree!

I think when you’re deciding which of these countries you want to base the rest of your life in, the idea of how your potential future children will be educated is vitally important. In general, the public schooling system in the UK is of a more universally higher standard than that in the US. That is an overly simplistic summary, of course. There are incredible free schools available in the US, there’s just fewer of them, and the disparity between a ‘good school’ and a ‘bad school’ is greater in the US than in the UK. This means it becomes even more vital where you end up buying your house, because school districts are tied to where you live. Of course, private schools are an option in both countries, and they are similarly expensive in the UK and the US, with tuition fees in excess of $15,000 a year considered normal.

When it comes to higher education in Universities, they are currently significantly more expensive in the US than in the UK. Let’s take medical school as an example. The average medical student in the UK will likely have accrued tuition fee loans of around $65,000 ($13,000 a year x 4 years + some “maintenance loan” for living costs) by the time they graduate. In contrast, the average medical student in the US will have accrued debts of around $250,000 (4 years of Undergraduate tuition fees + 4 years of medical school tuition fees + some “maintenance loan” for living costs.)

This is a huge difference. However, something to bear in mind is that there is a new, and welcome, trend in some US medical schools to reduce this massive debt burden. NYU School of Medicine announced in 2019 that it would remove all tuition free charges for its medical students moving forwards. Mount Sinai School of Medicine similarly announced it would be capping tuition fees for its medical school to $60,000 in total maximum. Let’s hope, for mine and maybe your sake, that this trend continues for decades to come!

The Exams

For an article titled “PLAB vs USMLE”, I know it seems strange that we got so far in before I’m talking about the actual exams themselves. Is this because I got so caught up talking about politics?

Yes, kind of… but also, no! There was a deeper reason behind me leaving this section to the very end. That’s because, it really should be the last thing you think about when you’re deciding on where you will look to build your entire future life. Exams come and go. Think about how stressed you were in some of your previous medical schools exams, and yet, now, if you were to look back on them, you would smile and realise that studying for them really wasn’t that bad in the grand scheme of things.

Let’s get some facts about the different exams out in the open first. First, the PLAB:

  • PLAB Part 1 -  written exam made up of 180 multiple choice questions which you must answer within three hours. Focuses on common clinical medicine content. 64% pass rate in 2019. Score does not matter for future job prospects. Costs $296.
  • PLAB Part 2 - an objective structured clinical exam (OSCE). It's made up of 18 scenarios, each lasting eight minutes and aims to reflect real life settings including a mock consultation or an acute ward. 66% pass rate in 2019. Score does not matter for future job prospects. Costs $1084.

Now, let’s do the same breakdown for the USMLEs.

  • USMLE Step 1 - written exam made up of a maximum of 280 multiple choice questions, divided into seven 60-minute blocks and administered in one 8-hour testing session. The number of questions per block on a given examination form may vary, but will not exceed 40. Focuses on basic medical sciences. 80% IMG pass rate in 2018, but score does matter for future job prospects (until January 2022, after this point it’s pass/fail only). Costs approx. $1135.
  • USMLE Step 2 CK - written exam made up of a maximum of 318 multiple choice questions, divided into eight 60-minute blocks and administered in one 9-hour testing session. The number of questions per block on a given examination will vary but will not exceed 40. Focuses on common clinical medicine content. 83% IMG pass rate in 2018, but score does matter for future job prospects (even after January 2022, will remain a 3-digit score). Costs approx. $1160.
  • USMLE Step 2 CS - clinical skills practical ‘OSCE’ style exam. It is made up of 12 patient encounters, each lasting 15 minutes + 10 minutes afterwards to write your note. 75% pass rate in 2018, but score does not matter for future job prospects (no number is given). Costs $1580.
  • USMLE Step 3 - not needed prior to application for residency. We won’t discuss this one for now.

Now, naturally, these are extremely concise summaries of what these USMLE exams actually contain, how they’re structured etc. We go into a tremendous amount of detail looking into things like their importance, the best time to take them, what resources to use, how to best use them, on the day tips etc. in our online videos, so make sure you check those out.

Whilst comparing the above information might make one think that the USMLE exams are easier because they have higher pass rates than the PLAB exam, the fact that the Step 1 and 2 CK exams both provide a numeric score that plays a big part in your strength as a future applicant, the preparation time and intensity for the USMLE exams is generally understood to be far greater than the PLAB.

It’s also worth bearing in mind what happens if you fail one of the PLAB exams vs the USMLE exams. Failing the PLAB exam, whilst frustrating and costly, has almost no long-term effect on your job prospects. Employers do not interrogate you on how many attempts you needed for your PLAB exams - once you’ve passed them, you’ve passed them. You are allowed to retake PLAB Part 1 and 2 up to a maximum of 5 times. With the USMLE exams, you are allowed to retake them as many times as needed to pass, but those assessing your application will see if you have failed any of the Step exams on the first attempt, and this will reflect badly on your application. Also, the more likely scenario is that an applicant may pass the Step exam, but with a lower score than they are happy with. In this case, there’s not much you can do. Once you have the score, you are not allowed to retake the exam for a period of 7 years, at which point it will expire and you will then be able to take it again.

Another obvious fact that you can see from my summaries is that there are 3 USMLE exams needed before you can start residency training in the US (Step 1, Step 2 CK, Step 2 CS) whereas there are just 2 exams for the PLAB (Part 1 and Part 2).

Finally, we can also see that the overall cost of the exams themselves are greater for the USMLEs (total of $3875) vs the PLAB (total of $1380).

Bottom line: the USMLE exams require more preparation time, are more expensive, are greater in number, and have higher stakes (a fail/ low score means more than failing the PLAB exams).

Conclusion

So… that ended up being long, but if you’re an international medical graduate from South America, India, Pakistan, UAE, North African etc. deciding on whether you’ll pursue a medical career in the US or the UK may be one of the biggest decisions you ever make in your life. I hope I’ve given a fairly exhaustive list of some of the factors that should go into your decision, and I also hope the information/advice provided in this helps at least some of your reach an educated decision on what is best for you.

Our purpose at LibertyMedics is never to persuade or convince anyone that they should move to the US for residency. Our intention is always to provide as much factual evidence as we can, so that our fellow doctors around the world can make up their own minds with their eyes wide open.

If, at the end of this, you decide that a career in the United States is what you want to pursue, then know that our course 'How To Make It In America' is here to help. We go through each and every step of the entire process; the pros and cons of moving, making the optimal timeline of when to take the Step exams/ apply, how to ace all 4 Step exams, how to get/ make the most of electives, securing LORs/ how to know what a good one is, ‘The Match’ application and interview advice, visas and immigration and more!

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