Doctors who travel overseas for postgraduate training represent only one feature of “medical migration,” which can be temporary or permanent and is a phenomenon that occurs worldwide for a variety of reasons. For drug interaction purposes, the inhibitors and inducers of CYP3A metabolism listed above can alter serum concentrations of drugs that are dependent upon the CYP3A subfamily of liver enzymes, including CYP3A4, for elimination or activation. So even while it's kicking warfarin off of albumin, it's ramping up production of 2C9 and 3A4-increasing the metabolism of warfarin.

2ĭoctors have travelled to other countries for training for many years. Cytochrome P450 3A (including 3A4) inhibitors and inducers. Remember that phenytoin is a pretty strong CYP inducer across the board.

In this week's BMJ, Sridhar argues that the United Kingdom should radically revise its practices in relation to overseas doctors seeking training posts (p 307). The United Kingdom has a long tradition of training overseas doctors-that is, doctors who gained their primary qualification outside the European Economic Area.

Christopher Welsh, regional postgraduate dean NHS Executive Trent, Sheffield S10 3TH.

Doctors in training cyp450 inducer