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A faulty production line

Half of GPs still critical of RCGP's handling of the CSA exam row

Almost half of GPs responding to a Pulse survey are still critical about RCGP’s handling of the CSA exam row, despite the fact a judicial review found it to be lawful earlier this month.

The survey, conducted this month after the judicial review hearing, asked 454 GPs how they would describe the RCGP’s handing of the controversy over the MRCGP exam, with 46% answering ‘poor or very poor’ - a decrease on the 58% who criticised its handling in a similar survey in October 2013.

The new survey also revealed that 63% of respondents said they did not think the MRCGP exam was unfair to international medical graduates (IMGs) while 14% said it was, which was a decrease on the 24% who said it was unfair in October 2013. An even smaller proportion - 12% - still thought it to be unfair to ‘non-white graduates’.

Prompted as to which measures could be taken by the RCGP to improve fairness of the exam, popular ideas among GPs included ‘better feedback on performance’ and ‘better preparation of candidates’.

The most recent survey was conducted after the High Court found in favour of the RCGP, ruling that the exam was not directly discrimantory to IMGs. However, Mr Justice Mitting said that the RCGP must act to address the differences in pass rates between white UK graduates and international medical graduates.

It comes as the British Association of Physicians of Indian Origin (BAPIO), which took the legal action against the college, said it was seeking a meeting with the Prime Minister about the exam.

BAPIO chair Dr Ramesh Mehta said: ‘The Government… needs to come in and ask what is going on, why all ethnic minority doctors are having problems… passing the exam, why they get reported to the GMC, why they are removed from the register, why they can’t progress in their career, why they can’t get excellence awards - everything is a problem.’

‘We are in the process of writing to the Prime Minister about it. We need to bring this to the attention of the PM… and hopefully find some way forward. We want the Government to take some positive steps to recognise the contribution of IMGs and ensure there is equality of treatment.’

Dr Mehta also said that a BMJ paper last week, which suggested that the standards of an exam taken by all IMGs before practising medicine in the UK needed to be raised, risked eroding confidence in overseas doctors.

He said: ‘The way the media in general portrayed the study as “foreign doctors are not up to the mark” was very bad publicity for everybody. I think it will reduce the confidence that patients will have in the NHS – much of which is run by ethnic minority doctors.’

A spokesperson for the RCGP said: ‘The recent challenge to the MRCGP was successfully defended by the RCGP in the High Court. We note that more than 50% of respondents felt the College’s handling of the MRCGP was good or very good.’

Survey results

Is the MRCGP exam unfair to international medical graduates?

Yes - 14%

No - 49%

Don’t know - 37%

Total - 454

Is the MRCGP exam unfair to non-white medical graduates?

Yes - 55%

No - 14%

Don’t know - 31%

Total - 449

How would you describe the RCGP’s handing of the controversy over the MRCGP exam this year?

Very good - 9%

Good - 44%

Poor - 38%

Very poor - 9%

Total - 442

What do you think should be changed about the MRCGP exam to make it fairer to non-white candidates? (multiple choice)

Better preparation of candidates - 42%

Videoing clinical skills assessment - 29%

More non-white examiners - 21%

Having a second examiner - 32%

Better feedback about performance - 51%

Nothing should be changed - 16%

Total - 421

About the survey: Pulse launched this survey of readers on 15 April 2014, collating responses using the SurveyMonkey tool. The 25 questions asked covered a wide range of GP topics, to avoid selection bias on any one issue. The survey was advertised to readers via our website and email newsletters, with a prize draw for a Samsung HD TV as an incentive to complete the survey.

As part of the survey, respondents were asked to specify their job title. A small number of non-GPs were screened out to analyse the results for this question. These questions were answered by 454 GPs.


Readers' comments (17)

  • I am not an IMG.

    Most GPs have never had to undertake the CSA exam but I am sure they are safe excellent doctors for their patients and colleagues.

    The mean mark of each cohort who sit the exam is close to pass mark, usually only a few marks above but sometimes even below the pass mark. Why is the mean scoring (or just below) candidate failing?

    The RCGP wishes to keep the CSA to ensure patient safety - yet most GPs are allowed to practice without ever having to take the CSA. Statistics from the exam show that you are less likely to pass the exam the longer it has been since you left medical school, showing that experience and wisdom may not help.

    If the CSA standard was introduced for all GP, a minimum of 5-10% (I suspect much higher) of GPs would not pass. Are these unsafe doctors? If they were not allowed to practice as GPs the uproar this would cause by patients, their colleagues and the department of health will cancel this exam.

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  • Una Coales

    My comment,'The High Court Judge made it clear to both the public authority regulator the GMC and the public authority delegated with administering the GP licensing exam, the RCGP, that now was the time to address the disparities in the CSA exam pass rates between British BME and white British graduates, between BME IMGs and white IMGs and between IMGs and white British graduates. Such actions could have, in my opinion, included more detailed exam feedback, installation of CCTV in 39 rooms (estimate £8k) for monitoring for unconscious bias and to provide evidence for fair appeals, revisiting the bar used prior to September 2010 when the pass mark for white British graduates was lower and for IMGs higher so as to reduce the disparity and offering GP trainees the option of the old video module in lieu of CSA for those who suffer from extreme performance anxiety.

    Understandably some GPs are unhappy with the 'actions' the GMC took by publicising a report on IMGs who sat PLAB and their subsequent performances at subjective Royal College exams like CSA which did not compare UK grads sitting PLAB so was not following a similar cohort throughout.

    I would hope that at a time when the NHS is haemorrhaging GPs, the RCGP will now adopt some, if not all, of the suggestions I had made known to them well before the legal action took place, so that BAPIO do not feel compelled to continue to pursue legal action through an appeal, an option offered to them by the Judge. Both the RCGP and GMC now have to show appropriate actions taken within a reasonable time, which in my opinion, would mean a year to get this right for all concerned to ensure we are not passing poor doctors or failing good doctors due to inadequate control of unconscious bias. Time to record all 39 CSA rooms, monitor for role player or examiner bias and allow tapes for fair appeals, as is the case with the USMLE licensing exam sat by both US and IMGs, with little disparities in pass rates.

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  • It is disappointing (and embarrassing) that it took a High Court ruling to prompt the College Officers to admit they needed to do something about this. If they focused on education and training, rather than how many times they can be interviewed on the BBC Breakfast sofa before being elevated to a national role at the DH as their political stock wanes, they would do their colleagues and our patients a favour!

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  • As Una Coales and Peter Howe aptly point out, its time the RCGP did a bit of soul searching and looked at what is wrong with this dreadful exam. As Anonymous at 6.58 , the first comment, rightly points out, the vast majority of GPs have not sat this exam and are safe doctors mostly, and if all were to be forced to sit it today , nearly 10% will not pass as experience and wisdom dos not count. It is indeed embarrasing that it took a High Court to make the RCGP and GMC sit up and listen. Till now they were hearing but not listening and looking but not seeing. A legal hand had to collar them to make them take notice ? Even if it was a financial set back it was a moral victory for BAPIO and for scores of IMGs of all specialities who have been wronged , ill treated, sidelined and careers crushed , to turn them into service providing fodder. The fact that such an action could even be contemplated and taken is a reassuring thing. The Establishment may not be intentionally out to get IMGs, but at a time when carefully crafted ` studies` are out out in the public domain denouncing IMGs as sub-standard and yet the Head of the Govt himself without any embarrasment says they need to recruit IMGs to help the manpower crisis , its time to sit up, take notice, and decide whether IMGs are needed or not and to either let them in, treat them well as equals and allow them to progress and prosper in theor career like any local doctor or just shut that bloody door in their faces once and for all, rather than killing them with the kindness of letting them in. Lets set the house in order, rather than just loooking up at the ceiling and whistling and hoping that no one will notice the clutter.

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  • Vinci Ho

    'Since people are already here, let's make them feel at home ' Analects, Confucius .
    Hence the authority has a duty to fulfil .......

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  • 7:18am - Summed it up nicely

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  • Far be it from me to agree with Una, but she has a point, and it may be the only way we are going to put this to bed for once and for all it to take on board some of her suggestions.
    However it would do GP and those that have passed well a terrible disservice if the exam and therefore GP is dumbed down. It cannot be seen that we are reducing standards or having differing standards to include poorly performing GPs.

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  • Vinci Ho

    It was probably easy to say ' we were only running an examination or a test, it was the job of those who provided the preparation for the test , hence go back to have more lessons in the driving school !'
    Truth is any authority should contribute to help those who are running into 'problems' in this test. They are the disadvantaged group. Aren't we supposed to help those who are disadvantaged in our society?(Label me as a socialist then)
    Can one introduce changes to make it 'better'? When there is a will, there is a way......I believe.
    Any leadership is about democratic , responsible but more importantly ethical politics. (Prime Minister of South Korea resigned today due to the poor handling of the ferry disaster)

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  • I am someone who failed CSA for 2 points and that thanks to an odd actress's behaviour in SCA station who was determined to destroy my station and subsequently my life, as it turned out. I appealed and spent £ 800 only to be told that I did not present sound evidence ( as it was my word against their word). How could I? Should the video recording been used I would have passed the exam with clear difference. I have successfully completed all other components of GP Training. I have been signed off as "Competent for Licensing" pending on passing CSA. All my assessors, EDs, GP Trainers, my GP colleagues think I would make a very good GP. For the peace of mind I have been assessed by independent CSA experts and they think I should not have a problem with the exam. I have had excellent feedback from my patients. I am for high standards, period. I still believe not everyone who enters GP Training should be able to get through that 's how it is in every medical specialty. My GP dream is dead for good. I am locuming hospital jobs and my life is simply ruined. Three and half years of hard work, family deprivation come to nothing. All I wanted was FAIRNESS, not favours. Video recording of the exam for purposes of proper appeal and/or two examiners in the room. Should the cost be higher I am prepare to pay for it , or let RCGP be clear: I might not like it but I would accept it and not go through that saga of torture.

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  • This comment has been moderated.

  • 7:28,
    same thing happened to me, failed by 1 mark, and clearly actor did delay me , and pretending the he did not understand me, after working in NHS for 12 years, real patient understand me, have 2 degree which were in English, If there were video in the exam, i could bring them to justice

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