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Gold, incentives and meh

400 potential new GPs trapped in MRCGP limbo as GP leaders call for reform

Exclusive The RCGP has estimated that around 400 doctors are stuck in limbo after repeated failures to pass its MRCGP exam, prompting GP leaders to call for the college to ‘look again’ at the exam.

The figures were revealed in minutes seen by Pulse of a meeting between the college and campaigners working on behalf of many of these doctors.

They have been in talks around potential alternative routes to registration, such as further training and an alternative licensing assessment.

GP leaders – including the former RCGP chair – have called on the RCGP to look at reforming the training process.

But the RCGP has said that developing an alternative assessment model would not be cost effective and would require an overhaul of the current regulatory framework.

It follows the row over the differential pass rates between white and black and minority ethnic doctors taking the CSA, which led to the college undergoing a judicial review.

The court ruled the MRCGP was lawful but urged the RCGP to take action around the number of BME doctors and international medical graduates failing the exam.

Candidates are given four attempts to pass the exam, after which they are barred from taking it again - unless there are exceptional circumstances.

GP Dr Narveshwar Sinha has been working on behalf of around 100 of these doctors, and minutes from his meeting with the college seen by Pulse, discuss the number of doctors ‘who have not attained the MRCGP’ - which the college estimates as ‘possibly around 400.’

Dr Sinha has been calling for these trainees to have further supported training time before undertaking an alternative assessment to the MRCGP.

However the RCGP has said many of these doctors already have difficulty providing robust evidence of their clinical skills and knowledge for the existing ‘equivalence’ routes to registration, such as the Certificate of Eligibilty for GP Registration (CEGPR).

The college’s minutes state: ‘CEGPR is generally not intended for doctors who had not managed to attain MRCGP and that it is usually for already trained and experienced GPs from abroad.’

But Dr Sinha told Pulse: ‘These 400-500 doctors who are already here, why don’t we use them rather than struggling to find doctors from Europe, or India or wherever else?’

This comes after Pulse revealed NHS England was in talks with recruiters about a ‘pipeline’ of nearly 600 European GPs, who could come to the UK in the next three years as part of GP Forward View commitments to recruit 500 GPs from overseas.

RCGP chief examiner, Dr Pauline Foreman told Pulse while the College was sympathetic to the problem faced by the GPs Dr Sinha represents, they couldn’t reasonably overhaul the exam.

Dr Foreman said: We explained to Dr Sinha that his proposal is not deliverable within the current legal regulatory framework, and that many of the changes required to enable it are not within the remit of the College.

She added ‘it would not be reasonable or proportionate’ for the College to develop a new licensing exam ‘for the small group of doctors who are unable to reach the standards’.

But former RCGP chair Dr Clare Gerada told Pulse she agreed the GPs could help the workforce crisis, and - while she didn’t think the CSA was discriminatory - the ‘whole process of working in the NHS disadvantages overseas doctors.’

Dr Gerada said: ‘I do think we should look again at alternative routes to MRCGP. Not letting people in who are not good enough, absolutely not. But we should be looking at alternative spaces where these GPs can work.’

Dr Krishna Kasaraneni, chair of the GPC’s education, training and workforce subcommittee, said: 'We’re set on the mindset that an exam proves somebody’s competence, the exam proves you can perform in that exam. Certain aspects overlap with competence, but because they’ve passed an exam doesn’t make them a good GP, and failing doesn’t make you a bad GP.'

'What we need to be able to do is to train GPs in an atmosphere where they get proper training in general practice from day one, rather than identifying problems when they’ve failed the exam a few times.'

Readers' comments (41)

  • Why on earth would you want to be labelled MRCGP knowing that you will have to pay for the title every year for the rest of your life. Is it same as having private number plates or buying a title of 'Sir'- seems insane though must concede it does make you look more knowledgeable than those who don't have that MRCGP tail behind their names. Finally, is this impotent and hopeless College actually worth it's name?

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  • Never did the MRCGP - was in training practice and offered job before did the exam so seemed pointless. Saved a considerable amount of money - Have given a lecture under the aegis of the RCGP in the past!

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  • Strikes me as odd that the RCGP don't try and gain greater buy in from the grass roots GPs by offering membership to every GP who successfully revalidates. In my day - MRCGP was the "quality" marker. however since it moved to nMRCGP as effectively the entry requirement to General Practice - all GPs who aren't members who are effectively doing the job are in theory as qualified as those newbies who just pass. If you say they aren't then what is revalidation about? are you saying a revalidated GP with 20 years experiences isn't as good as a straight out of registrar year GP? The college however with its elitist attitude still forces existing GPs to run through the MAP process. which is wordy and long and tedious. FAP i could understand and indeed I would think thats a better way of electing fellows that the mates club it is currently.

    I never finished my MRCGP as i got a partnership and didnt need it. I've been on a PEC and am now a GB member of the CCG - I also hold an academic position. Arguably I've done more for general practice locally than one of my partners who was elected an F by his mates down the road who are also Fs (for being a trainer). but I'm not eligible for membership unless I sit MAP - who has the time - reading the CCG agendas takes all mine!

    Until the college recognises good grass roots GPs and embraces them the college will be increasingly irrelevant. by bringing on all GPs - they could reduce the fee!

    I however think i know why they don't - its their club - would they still be voted to the top and hold all the plumb positions if real GPs were involved?

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  • The NHSE were trying to recruit 500 doctors from India with diploma in family medicine. Its is interesting that there are 400 doctors having done GPVTS training and failed NMRCGP who maybe more suitable for this than new doctors. I call upon BAPIO/BIDA to try negotiate the same for such doctors to work at least as salaried doctors in primary care as long as there are no performance concerns.

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  • Peter Swinyard

    It beggars belief that the government would rather that our patients had an appointment with a paramedic or a physicians' assistant than by using the talents of this group of GPs who, for whatever reason, are failing the CSA. I would rather see as a patient someone who has passed finals after a 5-6 year course, done house jobs and 3-4 years more training than a physicians assistant who has done some sort of science degree and two years training. These people must be welcomed - perhaps as staff grade GPs where they must work under supervision. But don't waste their skills, talents and enthusiasms.

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  • Couple of thoughts
    1 Any profession has to have entry criteria.
    2 These doctors maybe doctors but they shouldn't be referred to as GPs because they are not.
    3 There should be no limit to the number of times the exam can be taken.
    If doctors eventually reach the standard even if they take 10 goes and 10years, what does it matter?
    (How they do this is up to them, they may have to work as a physician assistant and pay for training out of their own pocket?)
    4 anonymous 10.50 makes a valid and an uncomfortable point even if he didn't intent to... Re validation is not an appropriate way to ensure that those who are GPs are upto standard. The only way is to sit the MRCGP exam. I suggest every 5years and this includes those coming from abroad. especially now there is Brexit.

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  • With regards to point 2) the headline has been changed to reflect this

  • Peter Swinyard

    I understand the comments of John Ashcroft about sitting the MRCGP exam every 5 years to uphold standards. This option was thought about and specifically excluded when revalidation was set up. There would be four probable results - [1]many GPs would pack up (you may say good riddance - but those of my generation for whom the MRCGP was optional have been learning constantly over their last 30 years but never had Multiple Diplomatosis and hated exams - do you say we are all incompetent?)[2]the Royal College would be rubbing its hands in financial glee at all the fees it would generate [3]Many GPs would say "bother this for a game of soldiers" and quit and [4] those who sat through it all would have to take vast swathes of study leave - how would we fund that and replace the bums on seats?
    No - it doesn't wash. Sorry.

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  • Why don't they all become physicians assistants and get paid a salaried rate to do everything?!

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  • GP is not a specialty its let's accept it ... A gatekeepers job to hospital.... You have to make decisions whether a person needs specialist or needs to go home, for that you need experience which these doctors had by training for three years here ..... Not exams, no exam prepares you to make a right decision..... It's just a way for RCGP to prove to themselves they are no less then other specialties.... And earn money.... Allowing MAP route to these GP trainees would not only help our dwindling GP workforce but also prevent the training of these doctors going waste.......every other specialty has option of CEGPR, so why not in GP.... Espy when we are facing such crisis of doctors....

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  • I did the exam in 2012 and I would say it was as close to testing GP competence in an exam setting as possible. There will always be "false positives" - poor doctors who pass and I'm sure many of the cohort who persistently fail would be excellent GPs but I think being passed purely based on an eportfolio or your trainers opinion might allow weaker candidates through. Doesn't stop me feel desperately sorry for the people stuck in limbo though the sums of money some have paid out are eyewatering.

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  • the best way to deepen the already severe recruitment is to introduce an MRCGP exam every 5 yars. It will add another way to quicken the demise of general practice as we know it. God forbid anyone who thinks so has any power to have this approved.

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  • This NMRCGP is another form of 'harrasement' in my opinion.

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  • In secondary care they have staff grade Dr's those Dr's did not pass higher qualification or did not attempt to do so but they are doing marvellous job.Why you have to pass MRCGP to do marvellous job ?patients don't look at your qualifications when they enter your clinic they look at your smiley face and watch your attitude towards them.Some Dr's In RCGP are paranoid.

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  • It seems reasonable to have an exam but is the MRCGP really teaching what we need? The CSA, in particular, seems to be failing good candidates and as I recall was more an exam in British social etiquette than medical competence.

    General practice is becoming more complex each year and we need diverse doctors that bring differing skill to the practice mix. The current exam does little to teach business skills, medical law and management - the stuff that keeps practices safe and functional. It's time to reform the MRCGP but I'm in agreement that allowing staff grade GPs without this qualification would be far better than leaving patients without access to primary care physicians.

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  • Good suggestions above. Like those posters I went straight into a partnership from VTS and then never had the time or the inclination to do MRCGP. After 25 years in the job and having jumped all the hoops for revalidation it seems an irrelevance to me now.
    PS let's hope that Hunt gets reshuffled soon! Might stop me from retiring

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  • 'Trapped in MRCGP limbo'!
    Sounds like a one way ticket to Hell!

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  • Having recently sat the CSA I must say it really wasn't that difficult. It did just feel like a normal morning surgery. I think if you can't pass after 4 attempts with some pretty extensive coaching and support they perhaps that candidate should consider an alternative career. Having a recruitment crisis doesn't mean we should be lowering standards. You can't even get a training number in surgery without MRCS never mind finish it.

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  • i have to disagree with John Ashcroft when he says

    anonymous 10.50 makes a valid and an uncomfortable point even if he didn't intent to... Re validation is not an appropriate way to ensure that those who are GPs are upto standard. The only way is to sit the MRCGP exam. I suggest every 5years and this includes those coming from abroad. especially now there is Brexit

    1. what are we doing revalidation for then? if the RCGP thinks its a waste of time say so and lets be shot of it.
    2. or why don't they campaign for the revalidation process to be more robust (more like MAP) and a pass means RCGP membership

    i seem to recall they've just watered it down?

    3 its arrogant to state that the nMRCGP is the perfect test to assess GPs in practice with experience and real case loads. its not reflective of the patients i see or deal with after 20 years in practice and doesnt allow the fact that i can ask colleagues/ consultants for help if needed rather than having to sort the case in 15 mins.

    4 there is no comment about the RCGP wanting to broaden its membership. its a bunch of arrogant GPs who think they are better than the rest of us - though i suspect few of them do anything like full time work.

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  • Agree with most of John Ashcrofts points.
    Sadly every profession has trainees that do not make the grade. This applies to all medical specialties including general practice equally as it does in accountancy or the legal fraternity.

    The 400 gps are not qualified hence are failing trainees, not gps. Why they are failing is likely to be varied in reason and severity however if they have had the additional 6 months of funded support beyond their standard st training we must be honest with them and say are will not be gps. Simply having a desire and experience of attempting to do the job does not make a good general physician,( which in essence is what we have become).

    Self funded training might be an option but this 400 reservoir of doctors should not be considered as 400 gps being held back from practicing due to red tape. They have not crossed the required line to do so.

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  • Dear RCGP why are you so afraid to VIDEO the CSA exam regardless of so much pressure to do so? I wonder why you are so afraid of transparency? IS THERE MUCH TO HIDE?
    One examiner per station, no evidence to challenge the examiner’s decision. Repeated high failure rate of one group of candidates of protected characteristics despite being selected by a competitive process for VTS training. Progression through multiple ARCPs over the years until the CSA exam. High stake exam yet no fair appeal process. It is astonishing this kind of things can happen in a country like United Kingdom where justice and fairness believed to be championed! Where is justice and fairness in case of MRCGP exam?
    -LWT

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  • I never sat the MRCGP as Summative assessment was the entry criteria when I was a trainee. I never felt the need, nor do I now, 20 years later, despite my workplace paying those with the MRCGP more than those without, despite there being no actual evidence that they are actually any better. As for the comment that the MRCGP should have elements of business and management, well, no. Not all of us work in NHS Practices.

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  • RCGP (Royal College of General Practitioners) should be renamed as ROYAL COLLEGE OF SPEECH AND LANGUAGE. RCGP is not testing the clinical abilities of doctors but some useless communication skills which will in no way save the life of any patient.

    Everyone knows that CSA examiners are all GP Trainers. In my opinion I feel that the GP trainers are to be blamed for this fiasco, because for various reasons ( eg increasing administrative work load, working part-time, becoming port-folio GPs etc) the trainers themselves end up having so poor clinical knowledge that the only way they can show that they are somewhat superior to the trainee doctors is in their ability to communicate with the patients.

    In most situations, when a GP trainee approaches a trainer and asks them a simple straightforward question about any clinical issue, they give bull s**t responses like - where do you think you will find the answers (with the lame excuse that this will encourage self-directed learning) but they themselves cannot admit to the fact that their clinical knowledge is no better than that of the trainee.

    Good communication skills do not save patients lives (except in some rare incidents where in patients completely misunderstand the advice given by a doctor) but poor clinical knowledge definitely does. Also just being able to communicate well does no make one a caring doctor.

    Patients would rather prefer to be treated by a doctor who has sound clinical knowledge even though they may not be having some exceptional communication skills.

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  • I am one of the unsuccessful doctor who fall into this group. I failed CSA exam by narrow margin of one mark on two occasions. My aspirations of becoming a GP was put to a halt in spite of having excellent patients and colleague feedback and Supervisor support. Would getting a mark less make me any less competent than someone getting a mark more? Would it not be appropriate in such circumstances to look at overall training and assessments before ruining someone’s career? Sad part of it is that we cannot even challenge the results.
    We are not asking to reduce the standard of training, it is about making sure doctors with potential of becoming a good GP are not lost in the process.

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  • What makes a good doctor!? The trainers do not know where to find the right answer, they only pretend........God bless

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  • Truely agree with @3.36pm.... I also failed by one mark.... And unlike other specialities .. Nothing to show for three years worth of training... No way to prove yourself.... No way to show that money spent on my training was well worth it.... And all other specialities happy to employ me except the one l spent three years in training, gaining experience, building doctor patient relationship. So sad all that has been ignored by RCGP, except Dr Terry Kemple, who has been so supportive and empathetic to our case, yet his hands are tied by RCGP. I have high hopes that Dr Lampard will revolutionise the college and put patient care and NHS above all the beaurocracy and rigid rules.A patient wants to see A doctor , who can help mitigate his problems, he does not care whether he has MRCGP, he wants to see A doctor , not nurse or physician assistant, yet with all the crisis of GPs, the patient is being denied this basic facility, and not least helped by the attitude of the college ... Denying doctors like me a chance to prove ourselves and help us and patients.

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  • Just goes to show how desperate things must be in India for these candidates to continue knocking on the RCGP's doors inspite of failing repeatedly and spending all that money in the process.

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  • When Dr Clare Gerada says ‘whole process of working in the NHS disadvantages overseas doctors.’ my heart sinks. I got my MBBS overseas. I think she is right. Could this be due to communication difficulties of overseas qualified doctors or due to patients' bias towards them?

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  • @5.06pm..... Wrong just goes to show how desperate the things are in UK that it's going knocking on India's door requesting its mere diploma holders, who are nothing extraordinary to come and work in UK as GPs...so much for ''high standards''...... History is proof that it has always been UK which has gone knocking on other countries door begging for doctors to come and join its sparse army of doctors...... In a country where sadly more often then not people prefer to drop out of school and be couch potato...being drip fed by the state benefit system ......no one really wants to work ... Let alone be a doctor..... Working under rules of people like Hunt.... Being exploited and paid mearge wages..... I don't'' wonder''...... I know things are desperate in UK/NHS

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  • I find it highly suspicious that so many of these doctors are failing marginally/by one mark. It brings into question the authenticity of these exams, raising an issue of probity against the college.

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  • Passing exams simply proves that you can... pass exams. Don't forget that there are other groups of people who can get discriminated against by the exam system - principally those who find the exam process itself terrifying, however good a doctor they are - and it's made worse if they feel that the current exam is their last but one chance to get into the job they've always wanted.
    There's a simple answer to all of this - remove the 'four failures and you're out' rule; and recognise that things need to be amended for those who are exam-phobic

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  • I am writing this since I am part of this large group of British trained doctors in GP programs whose career has somehow been devastated as a result of such unfair exam.

    I have already asked Terry Kemple to challenge me since I strongly believe I could have passed this CSA exam upon my first attempt and not failing this for 5 times and every time with only one mark when I did nothing wrong. I could have passed it if my performance was marked in a fair way.

    Let me give more background about myself. I had great clinical training experience from USA, passing all the USMLE steps including CSA all on my first attempt. Then I decided to become a GP in UK and in spite of all good records during my training, this exam has put a halt on my whole career.

    My question for RCGP is that how come USA has no examiner in their CSA exam and instead they review the recorded videos for marking it in order to decrease the bias? How come there is no fair appeal system in this UK exam?

    Our group of doctors are all knowledgable and experienced ones who are currently working in different departments of NHS or Private Healthcare with excellent feedback from their patients and colleagues on a daily basis. We have all been appraised and revalidated smoothly since finishing our GP training.

    I am just hoping the reshuffling of RCGP and most importantly the new Chair, Helen Stokes can be a constructive way forward for bringing us back to GP Land not only because of supporting us but also to help the nation as we are potentially the best option to resolve this crisis of lack of GPs.

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  • Mark Smith

    Same discussions are had in other countries chaps and chapesses. As a 53 year old lifelong UK GP who never bothered to retake MRCGP back in the day, I have had to sit the Australian equivalent which is just as controversial over here due to Internationals having a much higher failure rate. But having revised with some and experienced some of the poor quality primary care by those without the FRACGP (but allowed to work as GPs at a lower pay rate) I fully endorse there needing to be language skills AND an exam such as MRCGP because those trained in other environments are sometimes rather below par. Language skills are fundamental to a GP/patient interaction, without them, care given can be lazy/wrong/dangerous etc. There have to be high standards.

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  • Took Early Retirement

    I think those who fail to become GPs should be allowed to become consultant surgeons.

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  • John, it would be nice for those doctors to become colorectal surgeons and wish for them to have you as their first client. sarcasm is not an interesting talent of doctors, unless you see yourself as a good comedian, not a Dr.
    MRCGP has created a crises which made every GP around the country crying and mourning for not having enough staff, I doubt that the 400 doctors is an actual number, this what the college has admitted, for sure it is not reflecting the truth, also GP is not a specialty , it is vocational training which creates a good gatekeeper. Then you have revalidation which can prevent further Shipman, MRCGP IS a MONEY MAKER. It is the dying cow which has been milked to the end by RCGP, I didnt get to this fact until Clare Gerada questioned the necessity of the CSA/ MRCGP exam. There is no doubt that the clinical knowledge should be assessed in an exam, but assessment of communication skills should be assessed on day to day practice rather than one day exam.
    I hope the best for the mentioned doctors ( no doctor who has worked that hard , deserves what happened to them )
    farewell for the NHS we should do our best to keep it running and ensuring our patient's safety is in good hands (doctors hand, not nurse practitioners, paramedics or pharmacists, non doubtfully some are good in what they do , but not to become doctors/GP )

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  • It is utterly inexcusable that the RCGP is advocating the use of a skill mix to include paramedics, nurses, pharmacists and physician's assistants who have not even done basic medical training - yet they are not allowing doctors who have trained in GP IN THIS COUNTRY to work in some capacity.

    It's a mad, mad world.

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  • Bottom line is that RCGP exam is a money churner. More the failures and re-attempts, more the money pouring into RCGP coffers. Let's consider this fact of life and then think of those missing the mark by one point - a colleague mentions missing it by one point twice!

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  • Doctors who fail the exam are more likely to be:

    Older and more experienced
    Male
    UK trained and of ethnic minority
    IMGs

    I may understand why IMGs are more likely to fail – why does experience not help in this exam?

    What is wrong with male doctors?

    Why are UK trained doctors from an ethnic minority much more likely to fail?

    Dr. Aneez Esmail’s report into the exam in 2013 concluded that even after controlling for age, sex, and performance in the applied knowledge test black and minority ethnic graduates trained in the UK were four times more likely to fail the clinical skills assessment at their first attempt than their white UK colleagues.

    If this exam was part of revalidation – it would be cancelled within a day.

    The exam has a 25% failure rate – much higher for older candidates.

    Once these doctors are not allowed to practice any longer – the public outcry from this would kill this exam once and for all.

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  • Hi
    Having decided to pursue General practice as a career I enrolled to be a GP after leaving my job as a well established hospital Doctor.I underwent the rigors of training in different specialities to help me equip to be a competent GP .i passed my AKT on my first attempt. I worked efficiently as a GP trainee in my surgery needing little help or supervision, passed my work Place based assessments and had excellent patient feed back. My only hurdle was the CSA which is basically a exam of my English behavior skills. I had little support from my own trainers who had never been exposed to the CSA and were at a loss to understand what was the CSA trying to achieve. In a exam where the actor had his own agenda and react differently to a English and a non English Doctor how can the exam be deemed fair?This controversial exam is aimed at keeping GP as a exclusive club of the privileged few who can act rather than be good doctors
    It's a shame that during such a dire crisis the RCGP seems to be in denial of its own failings. I dare say there could be nearly a 1000 doctors in limbo (RCGP in denial for some unknown reason)due to this exam fiasco.Most of these doctors had no problems passing the other fellowship exams. So why the CSA exam is in news ? There is a lot of soul searching to be done by the RCGP as this has ruined our careers ,broken families and driven us bankrupt. Having entered GP in good faith as had a passion for general practice and to contribute to the nhs ,we feel lost and let down. I hope the RCGP will open its eyes and undo the wrong for this group of doctors .When having patients seen by a physician assistant or a practice nurse is acceptable why not use these group who are already trained and passionate to serve back as GPs. There are thousands of GPs practicing without the MRCGP so why this double standards?

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  • Not only should there be accountability but also follow up from the RCGP who has shown either an inability to or otherwise an unwillingness to deal with these 400 doctors whose careers have been ruined due to a failure to recognise and /or to react !

    Do either BAPIO or the BMA have a constitutional stance to propose a viable solution or will this be another BREXIT / Junior Doctor outcome that lingers on forever as the 'institution of General Practice is falling to pieces' ?

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  • RCGP should be accountable for creating this mess?Are the GP leaders sleeping?Shame on you.you dont have the guts to challenge RCGP

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  • Several investigations have cleared the RCGP of racial bias in the MRCGP exam and I have myself come across some of the people that have failed abd it would appear that the failure was amply justified.
    It is thus simple - if you fail then you have to accept a secondary role such as a "staff grade" or some equivalent.
    Maybe there should be such a level of posts created with the right to resit after a period of satisfactory performance in such a role.This would use the manpower so much needed at present.
    What do the other Royal Colleges do - do the appoint surgeons who have failed rcs 4 times? and so on.
    No more enquiries into the exam as it will be a waste of money.
    JRM Former Trainer : MRCGP 1972 and FRCGP by election.

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