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Neutralising bias in the Clinical Skills Assessment (CSA)

With complaints being registered about racial bias in the CSA, Dr Una Coales gives her view on how candidates can try to neutralise subjective bias.

With complaints being registered about racial bias in the CSA, Dr Una Coales gives her view on how candidates can try to neutralise subjective bias.

The CSA is a subjective exam in which, as with other social interactions, cultural 'bias' can come into play. But there are things you can do to minimise it.

Watch a video of your consultation and turn down the volume. Just focus on observing you. Now write a list of critical comments. Be harsh and honest. Your list could consist of ….too fat, dress is too floral, unshaven, dark skin, too camp, etc.

Yes, I mean be brutally honest as this is how the outside world may perceive us, including the actors and examiners who have never made our acquaintance. My list, as a GP registrar, read: hair too long, needs to be tied up in a bun, exposed all my arms, too much flesh, not professional, need to put on a suit and cover my arms.

I know what you are thinking. I can't change my skin colour. I can't lose 2 stone in 2 months. And why should I, when it makes no difference to be ability as a doctor?

Let's take the latter example to begin with. How do we neutralise a cultural bias against obesity? Patients take one look and are less inclined to heed your advice to take up exercise and go on a diet. You know what they are thinking. ‘Why don't you take your own advice!' The solution is to project an image of Father Christmas. Put your hands on top of your protuberant abdomen, with your fingers interlocking but open. This projects a paternal image and suddenly your patients and the observing examiner are not distracted by your majestic size. In other words you have neutralised a potentially negative observer bias.

Why is it not good to wear a floral skirt or dress? Patients judge you on your attire. If you dress how they perceive a nurse would dress, they have difficulty believing they are seeing ‘the doctor'. Sorry women, but despite the fact two thirds or more of new doctors are female, alas people still address my husband as Dr Coales. So for the CSA exam and when you're in post, I'd recommend wearing a black or navy blue conservative skirt suit to project professionalism.

Last week a patient declared to me that he wished to see me again because I was professional. I wore a suit. Members of the public also like value for money. They pay £100 for a 20-minute consultation with a private GP, expect him to be wearing a tailor-made suit with impeccable manners and think they are getting a better service. Irrational but there you have it, public perception - especially relevant in the context of revalidation incorporating patient satisfaction surveys.

If you have a beard or moustache and there are no religious reasons for having it (if you are a Sikh, for example), my advice is shave it off. It will grow back. What subconscious image might it project when a male professional sports facial hair…unclean, deceitful, hiding a weak jaw-line? It's hard to find positive traits. And as women are more judgmental than men and examiners are also invited from the Ministry of Defence, it helps to present a clean shaven face. Grooming is essential! And that includes removing nose piercings, multiple ear piercings and taking a shower to prevent b.o. I've seen it all.

Now we come to the sensitive topic of ‘race'. If there is any subjective bias based on colour, this is the fault of the examiners and the college and needs to be eradicated. But there are other factors.

Nigerians, for example, are quoted to have a CSA pass rate of 44% and Indians of 48% in the latest RCGP report. Having met numerous Nigerian GP trainees in my courses, I find their English fluent and most go on to pass but some candidates of Asian origin are more greatly hampered by language. For me, as a teacher, the male Asian candidate, for whom English is not their first language, is the most challenging to help clear this exam. If such a male candidate is based in Scotland or Wales, I ask him to focus on emphasizing the lyrical Scottish or Welsh accent. What I am trying to do is neutralise the immediate impression formulated that the candidate before the observer is foreign.

And finally the ‘too camp' category. One candidate was facing a 3rd sitting and yet no one had told him that his mannerisms, gait and speech were too overtly gay, and that he was sitting an exam administered by a right-wing conservative Royal College. So I advised him to lower and deepen his high-pitched voice and neutralise his body movements. He went back to his surgery, practiced his speech until his voice went hoarse and modified his body language.

Not only did he pass his exam but he informed me that he noticed a huge difference in the way patients interacted with him. QED.

All of my suggestions are simply about getting you through the CSA. They're about changing your image to get you through this one assessment. They're not about changing who you are.

Dr Una Coales: There are things you can do to neutralise subjective bias Dr Una Coales: There are things you can do to neutralise subjective bias

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