It is a common mistake to think that if you pass the right exams you can become a Clinical Microbiologist; it isn’t that simple. Believe it or not, passing the exams is the easy bit!
But before we get into all-of-that let me just tell you what a Clinical Microbiologist does… although if you ask the ECIC she’ll just say “drink coffee and eat cake!”
I like to think of Clinical Microbiologists as having a number of related roles:
- We are the interface between the diagnostic microbiology laboratory and the clinical teams
- We advise on the diagnosis and management of infectious diseases
- We advise on infection control
- We advise on antimicrobial stewardship
- We teach others about 1-4 above!
A diagnostic microbiology laboratory processes samples from patients to see if the patient has an infection, and if so, what the cause may be and what it might be best treated with. Yes, it may appear that the lab are the ones actually doing all the work! As someone in my laboratory once said, “if it comes out of the human body, we will play with it” or as I put it “if you can sample it, we can process it…” [That’s the royal “we”] However, the ward doctors have to be able to interpret the result the laboratory gives you! Unless you have a Clinical Microbiology service, then you might call us to do that for you?
One role of a Clinical Microbiologist is to look at the results generated by those clever Biomedical Scientists (BMS) and Medical Laboratory Assistants (MLA) and put a clinical interpretation on the result. The interpretation is based on the result, the clinical information provided with the request (if you gave it to us!!), and a knowledge of what antibiotics might be used to treat any given infection. Clinical Microbiologists don’t actually process samples, but they do need to know how to process the samples, likewise they do not call out every result, just the ones that are “significant”, of “interest!” or unusual.
For example if a purulent urine sample grows Proteus mirabilis from a patient in the first trimester of pregnancy, the Clinical Microbiologist will make sure the clinical team know that the bacterium is inherently resistant to Nitrofurantoin and that Trimethoprim shouldn’t be used in the first trimester as it is a folic acid antagonist and therefore can cause deformity in the foetus (known as neural tube defects). The Clinical Microbiologist might also make sure that Amoxicillin and Cefaclor are offered as potential treatments, one a simple penicillin and the other a possible alternative if the patient has a mild penicillin allergy (e.g. rash). This may sound complicated, but it’s a straight-forward result for a Clinical Microbiologist (the Lab I work with processes about 500,000 urines a year… yep, that’s about 12,500 litres of wee… and no we don’t have to wear rubber boots to do that!).
Another aspect of Clinical Microbiology is being able to advise other doctors about the diagnosis and management of infectious diseases. I get about 3,000 calls for advice a year, either about what tests and investigations to do on a patient or about what antimicrobials to use to treat them. I also do ward rounds in our Critical Care unit, and when Covid-19 isn’t around to mess things up I do ward rounds on the High Dependency Unit and the Medical Admission Unit. The purpose of these rounds is to help my colleague’s manage their patients as efficiently as possible, get the best use out of the diagnostic laboratory and the most appropriate treatment started as quickly as possible.
I am also involved in a number of Multidisciplinary Teams (MDTs) that manage some of the more complex patients we have, whilst also giving me an opportunity to have a “special interest” that I can really get my teeth stuck into. My particular MDTs are for infective endocarditis, cystic fibrosis, tuberculosis and neonatology and paediatrics. Others in the Clinical Microbiology team get involved in haematology, orthopaedics, vascular surgery, etc. It is really up to us what we want to get more involved in, sometimes we like the subject, sometimes the people, sometimes the biscuits and coffee on offer!
Clinical Microbiologists in the UK are also integral members of the Infection Control Teams of their hospitals. There is usually one member of the Clinical Microbiology team who is the designated “Lead”, but all of us are involved and can share our expertise and experience. I’m not going to go into detail about infection control but let’s just say the Infection Control Team (ICT) is there to make sure the hospital is as safe as it can be for patients and staff, and that it complies with all the relevant national legislation. Most staff and the public are much more aware of Infection Control (IC) and Personal Protective Equipment (PPE) nowadays!
Antimicrobial Stewardship is another big component of the role of a Clinical Microbiologist. When you look at a hospital antibiotic guideline in the UK then you can be assured it will have been produced by a Clinical Microbiologist, in association with a particular speciality, in order to make sure it is both safe and effective for treating the given clinical condition as well as avoids the “trip wires” leading to antimicrobial resistance or other such problems. For example, the community acquired pneumonia guideline will have been produced by a Clinical Microbiologist and the Respiratory Physicians, avoiding Co-amoxiclav which might lead to Clostridium difficile associated disease. Clinical Microbiologists also work closely with Antimicrobial Pharmacists to monitor the safe use of antimicrobials inside and outside of the hospital, with the aim to try and help control resistance and treatment complications e.g. Meticillin Resistant Staphylococcus aureus (MRSA) bacteraemia.
And then we try and teach all of that to other people… allowing us more time for a tea break… simple!
So, it’s a broad remit, and much involves “meddling in other people’s patients”, we don’t have our own patients. Does that sounds’ interesting to you? If so then this is what you need to do in order to become a Clinical Microbiologist in the UK.
What exams do I need to pass?
This is the question people ask when thinking about being a Clinical Microbiologist. Having short-listed and interviewed for many job applicants the first thing I would say is YOU HAVE TO BE A MEDICAL DOCTOR. Over the years I have had hundreds of applications from people who are not medically qualified. So, the first exam you have to pass is a Medical Degree, for me this was a Bachelor of Medicine (BM) degree.
But wait if this is not the route for you, there is one other! You can become a Consultant Clinical Scientist and perform PART of the role of a Clinical Microbiologist, but this is not a medical doctor nor does it lead to becoming one. It is a role for a BMS to aspire to or a route directly to Clinical Scientist. It is a different and increasingly important role within the clinical “tool kit” of a clinical microbiology service but I’m not going to deal with this here.
Once you have passed your medical degree and become a doctor, you’ll need to gain experience at Foundation 1 and 2 (F1 and F2, used to be a House Officer), then complete Core Medical Training (CMT, or the old Senior House Officer) and often take some more exams (MRCP or MRCPCH), then…. Yep it’s a long road…. You need to start higher Specialist Training (STs) which will vary in length from 4-6 years! Before taking even more exams.
The other exam you will have to pass is Fellowship of the Royal College of Pathologist (UK). This is a postgraduate qualification normally undertaken late in higher Specialist Training (see later). The FRCPath exams are notoriously hard, and they should be. It is essentially an exit exam from training and demonstrates that the person has acquired enough specialist knowledge to advise other healthcare professionals about infectious diseases. It is also important to note that the RCPath is in the UK, and so it is based on UK practice. To pass this exam you MUST be familiar with how Clinical Microbiology is practiced in the UK and the related UK legislation around Public Health and Infection Control. For example, many overseas doctors follow the American guidelines as set out by groups like the Infectious Diseases Society of America (IDSA) and then wonder why they fail the exam! The simple answer is that we have a National Health Service which is very different to the US health service, and our legislation and practice is also very different. If you want to pass the FRCPath exam you MUST be familiar with the UK practice found on websites like the Department of Health and the National Institute of Health and Care Excellence (NICE). Use practise or guidelines from the USA, the Americas, India, Australia or Africa or in fact anywhere else, and you will likely FAIL.
Many Clinical Microbiologists also undertake other exams along the way including membership or fellowship exams for other Royal Colleges, but these are not essential for those coming to the UK from overseas. In the UK it is not always expected that those entering higher Specialist Training will have acquired other Memberships such as Membership of the Royal College of Physicians (MRCP) or higher degrees like PhDs, in order to qualify for a training post; although these things can “help” if there is a crowded field of applicants. Back when I was training it was necessary to have membership of another college, so I have Membership of the Royal College of Paediatrics and Child Health (MRCPCH) as well as a Master’s Degree (MSc) in Clinical Microbiology [but he’s just showing off! – ECIC].
Many overseas Doctors think that as long as they pass the FRCPath exam they are qualified to be a Consultant in the UK, but this is only a small part of the process. The biggest issue for overseas doctor’s is having their experience and training recognised by the General Medical Council (GMC) UK to enable them to be entered onto the Medical Specialist Register. The FRCPath (part I and II) finalises the “exams” stage but it’s also about recognising the higher Specialist “Training” stage which allows a doctor to enter the Medical Specialist Register and gain their Certificate of Completed Specialist Training (CCST or just CCT as it was known). One without the other doesn’t cut it! It’s a long hard process to get a CCT in any specialty… and you’ll get no fanfare at the end of it!
General Medical Council registration and recognition
To practice as an independent specialist doctor in the UK (Consultant) you must have fulfilled criteria laid down by the GMC AND be on the Specialist Register. This is to ensure that every specialist meets a certain standard of excellence and can look after patients independently, safely and effectively.
For those training in the UK this is a relatively straightforward process. All higher Specialist Training programs in the UK are affiliated to a Postgraduate Deanery (ours is Kent, Surrey and Sussex KSS) and are approved by the GMC. You apply for and get appointed to one of these higher Specialist Training positions, you become a Registrar in you speciality, and then you complete the 4-6 years of training, pass your FRCPath exam, and then apply for a CCST. Once you have that training position the rest usually follows (a slow and painful learning curve but with the end result within reach for those who are prepared to study hard – it’s not an easy task; ECIC says if you do not feel like you are “in the jaws of death”, you are not finished yet!). The RCPath has set out a curriculum for Higher Specialist Training in Medical Microbiology, which all training programs would be expected to follow and which provide a good framework to see if your training is similar (especially if you are from overseas).
Once you have you CCST and are on the Specialist Register as long as you comply with the GMCs rules for revalidation and maintain your license to practice you are sorted. Put your feet up and take a coffee break J … I wish!
It is much harder for overseas doctors. It may sound unfair but not everyone who has been trained, and may even be working, in Clinical Microbiology from overseas is eligible for recognition by the GMC and entry on the Medical Specialist Register. Bear in mind that the same rules apply for UK trained doctors who want to work in other countries as well e.g. if I wanted to work in the USA or South Africa I would have to have my training recognised there as well, those countries expect me to sit their exams or “retrain”! It does feel a kick in the teeth, I do appreciate that.
In fact it can be easier to apply for a higher Specialist Training position than it is to have your previous training recognised. I have friends who have had to go down this route because their previous training wasn’t recognised by the GMC. It’s a tough situation but the GMC website does provide comprehensive information for what is required to work as a doctor in the UK. REMEMBER, being great at your job and the NHS’s need for your skills are not GMC criteria!
Experience of the National Health Service
The final key to being a Clinical Microbiologist in the UK is to have “experience of working in the NHS”. I know this might sound a bit odd as you can only get experience if you work in the NHS and surely you’d get experience of working in the NHS by working as a Consultant, but I have seen lots of doctors “new” to the NHS struggle.
To be honest I’m not really sure what makes the NHS so “different”, as I have little experience of working in any other healthcare environment. There are lots of documentaries on the NHS but the one I always remember was a BBC TV documentary where Sir Gerry Robinson, a top businessman, tried to streamline a District General and improve their waiting list times. He had to hold his hands up to recognising he didn’t understand how the simplest of things could not be achieved with all the resources yet the most complex of things were achievable without any resources… the NHS seemed an enigma to him, an “unmanageable monster!” (Sir Gerry Robinson). I suspect it’s because the NHS works almost through an internal barter system where people trust the advice of those they know and the main currency is “good will”.
I think it is essential for anyone who wants to work independently as a consultant in the NHS, whatever the Specialty, to have experience at a more junior grade before taking on a senior role. You just have to know how the NHS works in order to get on in it. Taking a junior role may be the ONLY way to get a foot in the door!
Another aspect of being a Clinical Microbiologist is one of temperament; sometimes you are asked for your advice and then the person either argues with you about your advice or ignores it completely… and you have to be able just to let it go. And that is sometimes easier said than done, especially when they then call you later and ask for your advice AGAIN having ignored you the first time! You do have to be a bit of a diplomat to be a Clinical Microbiologist and not take it personally.
So, there you have it, this is what it takes to become a Clinical Microbiologist in the UK. It’s very different to the Clinical Microbiologist role in most other countries, and often not what people expect, but if you can see yourself doing it then GO FOR IT! I hope you can now see how to get started, find the missing “evidence” of training and have a good strong arm to carry all those folders… good luck!