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Doctors with dyslexia are less likely to pass the CSA exam

Doctors with dyslexia are less likely to pass the MRCGP clinical skills assessment (CSA) exam than those who do not have the condition, despite reasonable adjustments being made, according to a study.

The research, published in Medical Education, concluded that more needed to be done to understand the problems encountered by doctors with dyslexia.

Results showed candidates with dyslexia passed the CSA at a rate of 85%, compared with the 96% pass rate of candidates who had never declared dyslexia. 

Researchers at the University of Lincoln looked at a group of 598 exam candidates who declared having dyslexia (2.9% of all candidates) during an eight-year period - 492 of whom declared their condition upon first attempt, and 106 who declared it at a later attempt of the exam.

The researchers compared these candidates with the 20,281 (97.1%) other GP trainees who did not declare dyslexia 'at any time'. Then the CSA pass rates from 2010 to 2017 were analysed and the two groups compared.

They found that those who had dyslexia were less likely to pass, despite having reasonable adjustments in place - and for those who declared their dyslexia at a later stage, they were even less likely to pass once they had failed the CSA.

Reasonable adjustments, such as allowing extra time or extra paper instead of an iPad, are put in place after a trainee's condition is confirmed by a psychologist.

Lead author Dr Zahid Asghar from the University of Lincoln said: ‘Doctors with dyslexia, particularly those who declare the condition after failing at least once, possibly because they are unaware of the condition or worried about declaring it, have a higher chance of failing. This suggests we need to understand more about what trainees with dyslexia find difficult about the clinical exam and what can be done to help.’

Professor of general practice at the University of Manchester, Professor Aneez Esmail said: 'Dyslexia is a broad category. Those with mild are very different from more severe forms in their abilities in exams. If students are qualifying to become doctors, they will have been given some support by their universities - at least in the UK. In order to get the support, they need to have been formally diagnosed – not just self-declared.'

Last year, the same analysis was conducted on the performance of the applied knowledge test (AKT), which found that doctors with dyslexia were no less likely to pass the AKT.

Corresponding author Professor Niroshan Siriwardena, from the University of Lincoln and RCGP research lead for assessment said they have been investigating differential attainment in the MRCGP exam and its causes ‘for some time’.

He added: ‘Our research is beginning to reveal important clues about why certain groups of doctors do less well at certain parts of the exam and what might be done to alleviate this.’

Sessional GP Dr Sudeshna Sar failed her AKT exam three times before declaring her dyslexia and passed the CSA on her second try. She explained that dyslexia affects people in different ways.

She said: ‘There’s a lot of distraction with the CSA. You’ve got two people sitting looking at you, you’ve got a camera going, you’ve got a patient who you know is an actor. Distraction is one of the main issues that dyslexic people struggle with.

'In my case, I got extra time, I also got a separate room as distraction was a huge issue. Dyslexics often write on a lot of paper so I got a lot of paper, I was given bigger fonts, coloured fonts, because a lot of us deal with number issues with colours.’

Dr Sar added: ‘It’s not just the AKT and the CSA. The issue I found was during training also, doing the portfolio, seeing patients, doing calls. It’s about learning strategies and identifying those issues because dyslexia is very different across the board.’

RCGP chair Professor Helen Stokes-Lampard said: 'The main purpose of the MRCGP is patient safety, but the College is also mindful of its obligations imposed by the Equality Act 2010 to make reasonable adjustments for disabled candidates and is at all times extremely sympathetic their needs in this regard.

'The exams section of our website outlines the processes in place for making reasonable adjustments for candidates with a disability, including those with dyslexia.'

In a recent interview with Pulse, incoming RCGP chair Professor Martin Marshall said the exams were not to blame for differences in results. 

He said: 'The most important thing that we know, from the evaluations that we’ve done and from a growing number of evaluations is that there is no evidence at all that it’s the exam or the exam process which is discriminatory.

‘We know that there’s differential attainment, we regard that as a serious challenge for us, something that we need to understand better than we do at the moment, but there’s no evidence at all that it’s the exam which is the cause of that or the process of the exam which is the cause of that.’

The RCGP has faced criticism recently for not following through with suggestions made to change the CSA exam, with regards to the differential attainment between white and Black and minority ethnic doctors.

The Royal College has previously reviewed the MRCGP exam to determine whether it is 'fit for purpose.'

Readers' comments (16)

  • ...is that so? declare your dyslexia and that's a straight ticket to failure!Jeez..

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  • Vinci Ho

    (1) To be fair not to play with sentimentality , it is difficult to declare an long-standing illness as a potentially contributing factor after several failed attempts .
    (2) BUT ( always a bit) , we are defined by our history ; after the Battle of Unconscious Bias (BUB , as I called it), RCGP, though exonerated, must learn lessons from history :
    ‘’This is the best reason to learn history: not in order to predict the future, but to free yourself of the past and imagine alternative destinies. Of course this is not total freedom – we cannot avoid being shaped by the past. But some freedom is better than none.’’
    Yuval Noah Harari, Homo Deus: A Brief History of Tomorrow
    (3) Hence , the college as an institution as well as establishment , cannot prevent people from raising issues about the pass rate discrepancy amongst various categories of candidates and hence , the credibility of the whole examination taking place on frequent basis every year . Only being introspective and self-conscious of the implications of the result pattern in each of these examinations and making sensible adaptations, is the way forward, in my opinion .
    The truth is what we are lacking in politics these days , are honesty , transparency and humility . Brexit is such a good teaching material for my future students from all backgrounds.
    And I am sure if I am to take the CSA examination now , I will fail as well??

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  • So the CSA should be assessing a standard that is the absolute base minimum to be an adequate GP.
    If you are just about good enough to be a GP you should scrape through the exam.
    If you are not good enough to be a GP, by only a little bit, then you should fail the exam by one mark.

    If there are adjustments that are reasonable for GPs to make in their working life, then ALL GPs can make them, and that should be allowed in the CSA for everyone.
    If there are adjustments that are not reasonable for GPs to make in their working life, then they shouldn't be allowed for those with extenuating circumstances.

    So needing lots of paper - allowed, for everyone.
    But needing more time, extra breaks or colour coded numbers - unrealistic in the GP surgery - so should be declined in the CSA.

    This is likely to be an unpopular opinion - but ultimately if this is an accurate assessment of the minimum standard to become a GP, then there should be no reason to lower that standard, at all.

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  • My observation--purely anecdotal. I know 4 trainees who failed AKT twice. They were all advised to be tested for dyslexia as a positive diagnosis would give them extra time in the AKT exam. Dyslexia was diagnosed. This late diagnosis of dyslexia seems odd in individuals who have excelled at school and got through medical school.

    I declare an interest as I also have issues with the over diagnosis of the following conditions

    1 ASD
    2 ADHD
    3 Adult ADHD
    4 ME
    5 Fibromyalgia

    Still if I fail my revalidation I'm going to get checked for dyslexia and all of the above.

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  • Wow, some pretty broad brush and ill informed prejudiced ‘opinions’ above. I’m guessing little experience and even less expertise at recognising and managing educational issues here. Best not to let your ignorance blight the careers of others!

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  • Well here goes a true story:
    I was only diagnosed with dyslexia at 29, whilst failing my membership exam... 5 times.
    Yes I was too old to have been identified in school or university( I was just told to do a career which did not involve essays!)
    I did approach the college who decided( at that time) no help should be given or the playing field would not be level for all examinees.
    Never mind, without a MRCGP I still worked for 20 years in General Practice, before returning to hospital medicine.

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  • The times had an article about a deaf and blind medical student in their 4th year being shocked by prejudice of doctors on her ward placement but not from patients.
    Lots to discuss there.

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  • RCGP chair Professor Helen Stokes-Lampard said: The main purpose of the MRCGP is patient safety- and has it done that?? With patients waiting 12 weeks for an appointment and with retention and recruitment issues. Typical "Chairs" and Desks of the NHS beuraucracy that frequently spew s**t when they open their gob.

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  • @ Nostradamus horoscopes | Hospital Doctor30 Sep 2019 1:59pm

    Well yes,
    NO SERVICE is legally far more defensible than POOR SERVICE.

    As an aside: generally, medical professionals are responsible for ‘poor service’, whereas politicians and managers are responsible for ‘no service’.
    Funny Old World!!!

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  • This was d

    So while I know my opinion my not be popular, I just think I should clarify what I think.

    I am absolutely happy for more time to be available for the AKT. That mode of examination is not the same as practice and does not test the same things as running a consultation.

    But if (and a big if) the point of CSA is to match the environment that a GP works on a day to day basis, the ability to pass the CSA should be the same as the ability to safely run a clinic.

    If the two don't match, then the exam needs to be updated or scrapped.
    If the two do match then the ability of certain groups of individuals to have adjustments must be made carefully. It should only be what is available in actual practice; and therefore should be available for everyone.

    If, for example, you need more time to accurately read the notes in the CSA, you would need more time to accurately read the notes in real life. If that is acceptable in real life, then more time should be available to all in the CSA. If that is not acceptable in real life, then you cannot have GPs passing the CSA just setting themselves up to fail in real life.

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