Getting your first NHS job as an international medical graduate is a genuine achievement, often the reward for years of exams, applications and expense. It is also, if we are honest with you, the beginning of a second learning curve that has almost nothing to do with clinical knowledge. The medicine you already know. What nobody quite prepares you for is the system — the culture, the shorthand, the unwritten rules — and the first ninety days are where you either find your feet or spend months feeling permanently on the back foot. Here is what actually helps.
Before you start: the admin that trips people up
The dull logistics have a habit of becoming urgent if left. In your first weeks you will need to be registered with the GMC with a licence to practise, sorted for a bank account and National Insurance number, enrolled in the NHS pension (you are in by default — understand what you are paying into), and set up with an NHS email and smartcard. Chase the smartcard especially; without it you cannot order investigations or prescribe electronically in most trusts, and it can take longer to arrive than anyone admits. Build in some financial runway too, because the first full salary payment can be a month or more away.
Week one: learn the system, not the medicine
Your clinical competence is not really in question — but where things are is. Spend your first days working out the practical scaffolding of the job:
- How to order bloods and imaging on the trust's system, and how to chase results.
- How electronic prescribing works, and where the guidelines live — most trusts have their own antibiotic and prescribing app or intranet.
- Who does what. The nurse in charge, the ward clerk, the pharmacist and the healthcare assistants know more about how the ward runs than anyone, and treating them as colleagues rather than subordinates will make your life immeasurably easier.
- How to make a referral and how to call for help out of hours.
Nobody expects you to know these on day one, and asking is a sign of safety, not weakness.
Communication: the biggest adjustment
The single most common piece of feedback IMGs receive is not about knowledge; it is about communication style. British clinical culture leans heavily on indirectness and understatement, and this catches many excellent doctors out. A consultant saying "I wonder if we might consider" is very often giving a firm instruction, not floating an idea. "That's interesting" can mean "I disagree". Patients, too, expect a gentler, more collaborative register than in many health systems — shared decisions, not doctor's orders.
Most IMG difficulties in the first months are not clinical at all. They are the gap between knowing the medicine and reading the room. The good news is that the room is learnable.
Two habits help enormously. First, learn SBAR — Situation, Background, Assessment, Recommendation — and use it for every referral and handover; it is the shared language of the NHS and using it marks you out immediately as someone who fits in. Second, when you are unsure whether an instruction was firm, simply check: "Just to confirm, you'd like me to start the antibiotics now?" Nobody minds. Everybody minds a misunderstanding.
Ask for help — it is expected, not frowned upon
In some training cultures, calling a senior is an admission of failure. In the NHS it is the opposite: escalating appropriately is a core safety behaviour, and seniors would far rather take a phone call than discover a problem the next morning. Know who your seniors are on every shift and how to reach them. The phrase "I'm not sure about this and I'd value your advice" will never count against you. Struggling silently and getting it wrong absolutely can.
Look after the person, not just the doctor
The first ninety days are emotionally heavy in ways that surprise people. You may be far from family, homesick, managing a new currency and a new culture, and doing all of it on nights. This is normal and it is temporary, but it is real.
- Find your people early — the trust's IMG or international staff network, your fellow new starters, a mess or WhatsApp group. Isolation is the enemy.
- Register with a GP for yourself. Doctors are notoriously bad at being patients; be the exception.
- Know that occupational health and staff support services exist and are confidential. Using them is sensible, not shameful.
Start building your portfolio from day one
Your NHS career runs on evidence, and the doctors who progress smoothly are the ones who capture it as they go rather than scrambling before an appraisal. From your first week, keep a record of your work: collect the occasional workplace-based assessment, note reflections on cases that taught you something, and log any teaching or audit you get involved in. Ten minutes a week now saves a frantic weekend later, and it quietly builds the case for your next post.
The ninety-day view
Give yourself the grace of a realistic timeline. Most IMGs describe the first month as disorienting, the second as tiring but improving, and somewhere around the third as the point where the system finally stops feeling foreign and the job starts feeling like a job. The competent, confident doctor you were before you arrived has not gone anywhere — they are simply learning a new set of surroundings, and surroundings are learnable in a way that clinical judgement, which you already have, was not. Be patient with yourself, ask freely, look after your own health, and the NHS becomes not a hurdle but a place you belong.