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Independents' Day

International doctors advised they have 'strong legal case' against RCGP exam

Exclusive: The Indian doctors’ representative body has been advised it has a ‘strong legal case’ for action against the RCGP over the high failure rate of international medical graduates taking the College’s exit exam.

Dr Ramesh Mehta, the chair of the British Association of Physicians of Indian Origin, told Pulse it will continue to prioritise ongoing discussions ith the College, but it has received legal advice that supported a possible judicial review application.

BAPIO has begun collecting funds for a possible legal action and held an emergency meeting on Saturday to discuss the failure rates of IMGs taking the clinical skill assessment (CSA) component of the MRCGP.

The development came as RCGP chair Clare Gerada sent an email to members over the weekend saying the College is taking matters ‘very seriously’.

‘The issue about the exam and the high failure rate of overseas graduates is something that continues to raise its head and it’s really important that you know where the College stands,’ she wrote.

‘While we might not be ‘out there’ contributing to the noise as much as some of you might prefer, we take such matters very seriously. This is a very sensitive issue and a lot of work is being done behind the scenes.

‘The College is the standard setter for our profession. We exist to improve patient care and to that end, we must ensure that our assessments are as robust and rigorous as possible and that the trainees going through the process are the very best that they can be.’

She said there had been ‘noise’ on Pulse and Twitter about the issue.

She added: ‘It’s unfortunate that people can hide behind anonymity or choose to air their grievances in public, knowing that the College will never break confidentiality or fight its battles through the media.’

Dr Gerada added that the failure rates for the Applied Knowledge Test, which is anonymised and marked electronically, showed similar patterns to the CSA.

‘I hope we are now in constructive dialogue for moving forward. There will be another meeting in the New Year, to which we have also invited COGPED, and I will keep you posted,’ she said.

Dr Mehta said the weekend’s conference was an ‘emotional meeting’ with around 40 people attending.

He added: ‘Our trainees feel angry and demoralised about the way the assessment is carried out. We have received initial advice from our legal team. The advice is we have a strong case against the fairness of the assessment. That was encouraging for the trainees and they decided to start collecting funds.’

‘However, the BAPIO Executive said it will continue to collect funds but it would rather continue dialogue with RCGP. We will try our best to find a negotiated settlement.’

Readers' comments (147)

  • UK born child of Indian parents ....You are lucky thank your parents. They must have dreamt that my child will get the best, they left their homeland came to completely different CULTURE slogged day in day out to make you what you are .......So your success is really not yours..Call them tonight and say THANK YOU Mum and Dad for what you have made me today. Trust me you will feel happy

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  • Instead of commenting on BAPIO and Dr.Coales , Clare Gerada RCGP chief should concentrate more on doing things (behind closed doors atleast ) that make some sense like video recording.It would be useful for training the trainers and also for good feedback. Second most important thing is to reduce the fee for the exam which is highest of all membership exams.

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  • Thanks Rajesh.
    I am also of the same thought.

    1) Big time ! PLEASE TRAIN THE TRAINERS.

    2) MRCGP is very expensive . I have one attempt left but already in debt after 3 sittings , 3 RCGP course, 1 Emedica course and cannot afford the next or may sitting.

    Currently off sick . I don't know what to do.

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  • If you fail then it's because you have not sustained the necessary level to be a safe & competent GP. The selection process should be looked at because lots of good British Dr's get overlooked.

    If you fail your finals then you have one chance and not multiple chances like it's been proposed.

    In Canada if you fail the MCCEE then you don't work full stop & you can't use the excuse that you are an IMG so why here? Where is the equivalent of the BAPIO in Canada for the failed IMG's?

    Hope the RCGP does not waste member's fees on this debacle.

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  • @9:35
    Well court will decide who is competent and who is not.
    Unfortunately, I think you are not aware of the Canadian system AT ALL.
    MCEE is not a exit exam, it's an EXAM equivalent to PLAB and USMLE.
    I think , over here in UK, you need to clear PLAB first. You cant work without clearing PLAB....Can you?
    Similarly, in USA, you can't work before clearing USMLE. Can you ?

    In Canada, inf act you need to MCQE 1 as well..and some provinces want MCQE before you can apply for a residency....these are ALL EQUIVALENCY exams....
    SO PLEASE GET YOUR FACTS RIGHT BEFORE MAKING COMMENTS.
    In Canda, after you cleared your entrance exams, then you apply for residency in family medicine a.k. a GP training over here. It is a 2 year training and NO ONE GETS THROWN OUT after 2 years.
    PLAEASE DON'T make STATEMENTS about Canadian system about which you don't even know whether MCEE is entrance or exit exam....Speaks volume about your knowledge.

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  • @9:35
    Well court will decide who is competent and who is not.
    Unfortunately, I think you are not aware of the Canadian system AT ALL.
    MCEE is not a exit exam, it's an EXAM equivalent to PLAB and USMLE.
    I think , over here in UK, you need to clear PLAB first. You cant work without clearing PLAB....Can you?
    Similarly, in USA, you can't work before clearing USMLE. Can you ?

    In Canada, inf act you need to MCQE 1 as well..and some provinces want MCQE before you can apply for a residency....these are ALL EQUIVALENCY exams....
    SO PLEASE GET YOUR FACTS RIGHT BEFORE MAKING COMMENTS.
    In Canda, after you cleared your entrance exams, then you apply for residency in family medicine a.k. a GP training over here. It is a 2 year training and NO ONE GETS THROWN OUT after 2 years.
    PLEASE DON'T make STATEMENTS about Canadian system about which you don't even know whether MCEE is entrance or exit exam....Speaks volume about your knowledge.

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  • @9:35
    I guess you didn't know that MCEE is equivalent to PLAB !!!
    No one is thrown out of family medicine residency after 2 years of training! It's tough getting the residency as you need to clear equivalency exams, but once you get the residency, no one throws you out !

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  • Have failed CSA 3 times, going for 4th and final attempt in february.

    Trainer has no idea how to help me further ( all WPBA good, video and joint consultations all fine )

    Deanery is keeping quiet.

    RCGP - busy on twitter.

    I have started St Johns Wort.

    For Gods sake. Will someone please tell me what the f**k I have to do to pass this exams.

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  • @11 am
    Don't sit the exam
    Tell them to forward it to may .
    We ask for nothing but judicial review.
    Failing this exam is no more individual but a social problem. It is shameful RCGP is conducting the march sitting.

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  • I believe majority of the examiners and actors just, fair and conscientious people at HUMAN LEVEL. At least that is the way we want to think/see ourselves. When come to this apparently CONTROVERSIAL EXAM, the examiners show the typical human instincts UNCONSCIOUSLY. I am sure they themselves would be surprised and be very upset of their conduct, if one can prove such UNCONSCIOUS BIAS is contributing to the mind blowing statistics on this exam.
    Such validated scientific experiments do exist. Easy to perform. Reproducible on various ethnic groups in the world.
    Thinking about cooperation for such measures makes me undoubtedly looks very naïve to the observer while the college STRUGGLES TO DEMONSTRATE TRANSPARENCY even on very basic measures like VIDEOING the examination to ease the perceived and demonstrated discrimination ???
    Human behaviour fascinates me.
    LWT

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  • Merry Christmas all.

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  • Judges are fair in this country. And IMGs have a strong case. Onus is on college to prove that exam and the results have been fair. BAPIO did not design this exam.

    What is concerning is people who very recently were in the RCGP council are taking the college to court. This is like Professor Peter Rubin saying I think GMC is unfair!

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  • ((Judges are fair in this country))
    In an open environment no one wants to behave as he or she like.
    Rules are clear and straight for some reasons in the UK, so he has to behave according to the book.
    Chair claimed the similar pattern observed in AKT. Just curious to know how many IMGs are out of training due to AKT failure??

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  • For years there happened to be people becoming GPs of high credibility withasessments with no such discrepancy like witnessed now so whats happened now. I went for pratice in CSA exam centre and asked the Actor during scenario what stress he was under which he neither the acting examiner thought of pointing when they gave me feedback that he was under stress- Bias yes tremendous, .Actor as well as examiner .Could RCGP tell us the GOLD Standards for designing the exams and why they have slept through till now and not interacted with the aggrieved peope?

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  • RCGP will continue to sleep through until you wake up and challenge the system!

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  • Ever since the " noise " began, why has the RCGP / Clare Gerada not made a single comment re videoing these exams and providing them to trainees to use as evidence in their appeal process ??

    What is so difficult about videoing these exams ? Or is the RCGP worried about something ??

    Seems like a very simple and reasonable request from the trainees !!!

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  • https://www.theabfm.org/moc/passrate.aspx

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  • Thanks for this, Una.

    But the whole US background is different n'est ce pas?

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  • Dear all
    Lets fight against the injustice against the injustice against IMG GP trainees;
    Please donate generously to help BAPIO help you and your family in their endeavour against the gross injustice.
    BAPIO Account Number 00066608 Sort code: 30-90-66 Lloyds Bank
    Please quote Ref: CSA

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  • CSA 4 attempts rule was implemented in August 2010. How can the RCGP/Deanery can retrospectively apply this rules to those who already started their training?

    All the trainees so far affected started their training prior to August 2010

    I found this link on the web...
    http://elumnus.co.uk/2010/08/03/new-rules-for-mrcgp-akt-and-csa-examinations/

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  • I have been a trainer for 30 years and have of late specialised in helping registrars in difficulty which usually means IMGs
    These are the issues:-

    1] The CSA for good or bad is about high level communication this requires a perfect understanding of idiom, and local culture. I speak reasonable French - but would have no chance at a French CSA - and it is because of this that doctors who were not born in the UK find the exam so challenging, this is not a colour effect it is a language and culture effect!

    2] If we feel excellent communication is crucial to primary care the exam should be kept in its present format - however if we can accept that it may be possible to practice an acceptable standard of medicine without such skills it could be levelled down

    A possible solution would be to return to the time when the end of training exam was deemed adequate for registration and the MRCGP was the mark of excellence

    A safe caring doctor has just failed her CSA for the 9th time in our practice and been released from training.

    Throughout her time with us she did not receive a single complaint from a patient which is quite unusual , She had a well above average clinical knowledge and was a good medical opinion.
    She failed as she had problems with high level communication - but not ones which were reflected in her ability to work as a GP in everyday practice. She would not have been a great GP but in my view would have been a good enough GP

    The college needs to think carefully about what it is trying to achieve. I am for high standards and excellence as an aim but perhaps good enough is and should be good enough
    Mark Feldman

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  • re 1028pm

    Do you really think that the RCGP would be allowed by the GMC to change the rules retrospectively?

    1051pm shows that there are still people doing it well beyond number 4!

    Hopefully you are better at medicine than at reading the regulations.

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  • I agree with Dr Feldman.

    I am American and now have failedx3
    I am disillusioned as trainer has no answer.
    I probably give up now as I cannot "talk British"

    I urge the college that if CSA is staying and they will defend the exam in court then it should be part of recruitment process in order to ensure tax payer's money is invested in the right kind of people i,e GPs with "British communication skills"

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  • Dr Feldman,
    Please contribute and donate to BAPIO.
    There are two more points that one might want to add.
    1) if the requisite comm skills are not what dr Gerada wants then she should not take all these ppl in the training in the first instance. Unfortunately, currently, rcgp is minting £10-17k from each one of them and throwing them in the bin like a used tissue. What about ethics & value over here??
    2) were the drs produced before nov 2010 not safe ??
    And also all those trainees who had already started training in 2008 and 2009 may have not joined GP training with these restrictions. You don't change the rules of the game at half time. Therefore, what gives her the authority to apply changes retrospectively??

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  • I agree ...retrospective changes..legally on shaky grounds already.

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  • MRCP also, not only MRCGP

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  • Dear Dr Feldman
    You have hit the nail on the head. Being an experienced trainer you can clearly see where the problem lies. Unfortunately the Hierarchy in the college is ignorant of whats happening at the grass root level. I worked with a CT surgeon who was the best in his job but had to ask his juniors to do presentations for him.
    Communication is important but if we talk about globalization where people from all over the world are working all over the world, it should not be the main aspect of a clinical/ medical examination.
    Forget English in the UK how many UK graduates will find it easy to take a similar examination in Australia or Canada, not many.
    The vision or the goal the present CSA format is trying to achieve is not ideal for IMGs and is putting them of big time. In the interim there are a lot of IMG doctors who have put through this transitory phase which they did not expect, as somebody has said that rules of the game is not changed midway.
    If RCGP goes to the court I am sure that the retrospective change in the MRCGP exam for people in the system before sept 2010 will be lost as it happened in the HSMP case when the Home office tried to do something similar.
    RCGP ideally should reconsider this exam and warn IMGs not to go for GP as a career as there chances of passing the exam is very low.

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  • Dr Feldman
    Please don't mistake me. This is for RCGP to understand
    If it is language and culture effect - then why take IMG's into GP training in the 1st place. For all IMG's English is only a second language and they can communicate to a level where any patient can understand their communication. They may not be able to cite the best examples or use the best possible vocabulary but that is not a must for treating patient, that skill is only an added advantage.
    Do you think all those IMG's who have passed have got excellent communication. It could have been a lucky day & could have had less bias with less number of competitors (local graduates) on the day they took the CSA.
    RCGP has ruined the career of many IMG doctors. If they felt that our communication is not good enough for their job why did they select us in GP stage 3 selection ?? to make money. ?? To get cheap labour for 18 months in GP surgery .

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  • 1:47

    Yes precisely. Cheap labour in GP surgery and hospitals to fill rota gaps. By the way, interesting analysis from Mark.
    I think if there is an opinion amongst the RCGP exam body that one requires excellent communication skills and not just "good" communication skills, then they must filter this at the entry level tests.
    My car instructor told me I will be ready for the practical driving test after 6-8 classes. And I passed first time. For my wife, he said 20-25 classes and she passed in second attempt.
    RCGP needs to get their act together and start self evaluation process. It's not rocket science that we are debating on about here. This is not an English PhD exam. This is a Medical exam. Shipman had excellent communication skills. Bristol baby surgeons were excellent communicators. Mid staff enquiry was Not about a doctors communication skills- it was about lack of empathy.
    I agree with Mark. College needs to look at what exactly it is trying to achieve. If the focus is on linguistic, vocabulary, and fluency of spoken English then they should consider having an English linguistic expert at least for example a professor of English literature.

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  • Good Morning all,
    www . bapio.co.uk
    Click "GP trainees in difficulty ."
    Please read and donate generously .

    As widely publicised by the Team at college , this is a "noise" created by "failed" doctors.
    The case is other way round.
    The concerns are >30% difference in pass rates in CSA(exit exam for GP trainees) based on their ethnicity.
    This indicates bias. We ain't saying it is intended but is being constantly ignored.
    Any skill can be learnt . GP trainees go through a three step assessment process . They surely are to that level where they can be trained to be GPs so why failures at this level
    Is the training flawed?
    ....

    Please donate to CSA legal challenge fund .
    We need money to get this sorted.
    It is now or never.

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  • This comment has been moderated

  • CSA stand for Clinical Skills Assessment (CSA)
    NOT communication skills assessment.
    RCGP change the name of the exam first to imply what is been tested in the exam.

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  • what is the update any one knows re CSA legal challenge fund.

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  • Dear Dr Feldman
    kudos for being open and honest in your views.
    your comments give some solace to those souls who haven't had any happiness even during these festivities and who have to spend money on reapplying for CSA and also contribute towards the legal challenge rather than buying gifts for their children.
    Most of the local trainers and graduates share our sorrow. Its a shame that RCGP and the deaneries are against us and seem to sit silently on this issue.

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  • Its hard to see how the bias falls in a computer genrated exam of knowledge and perhaps it isn't unlikely that the CSA section will be failed if knowledge is alos failed?

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  • comment @ 10:07am
    can you elaborate on your comment?

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  • @ 11:10 pm
    "Do you really think that the RCGP would be allowed by the GMC to change the rules retrospectively? "
    "Hopefully you are better at medicine than at reading the regulations"

    I am quite amazed by this and would like to say it such reflects your little/nil your knowledge on the issue.
    It would be a good idea to read regulations yourself before making comments. Let me shed some light to increase your zero knowledge on the subject matter.
    Those who are giving more than 4 attempts which you quoted are those who started training in 2007 or prior to 2007.
    Those who started training in 2008 and 2009, the rules & regulations were same as trainees who started training in 2007 and prior to 2007.
    After these trainees completed ST-1(2009 trainees) trainees and some ST-2 ( 2008 trainees), the rules changed in 2010 and said would also apply to the trainees in 2008 and 2009 ( this is what we are talking about)--->"changed rules retrospectively", these trainees were mid-way in their training.
    In simple words, for these trainees the changes were APPLIED RETROSPECTIVELY, which is WRONG as they were already 2 years in training and some 1 year in training.
    So my friend, yes it did happen, which contradicts a previous verdict from the court that 'changes can't be applied retrospectively'.....Hence, it again needs to go to the court as some brain dead people are not listening.

    ...

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  • @1007
    how many IMGs are out training because of AKT failure.

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  • Please revisit this article from Pulse 26 January 2011.

    The RCGP knew all along what was going to happen. And they didnt care !!

    http://www.pulsetoday.co.uk/rcgp-broke-rules-in-toughening-up-clinical-skills-exam/11051266.article

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  • @10:07
    don't try to muddle the issue with AKT, these tactics won't work, get real!

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  • DEAR ALL,

    PLEASE DONATE WHATEVER YOU CAN MANAGE! EVERY BIT COUNTS!

    I REQUEST ALL GP TRAINERS, HOSPITAL CONSULTANTS, EVERYONE WHO BELIEVES IN JUSTICE, EQUALITY, TRANSPARENCY & FAIRNESS .

    BAPIO ACCOUNT NUMBER : 00066608
    SORT CODE : 30-90-66
    QUOTE REF: CSA

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  • Dear Dr Feldman,
    Thank you for your enlightening post, which provides a glimpse into the mindset of the typical RCGP examiner. In fact, your post is a microcosm of the RCGP policies.
    Here's how:
    1) You have mentioned 'high level communication'. Although it sounds impressive, it is a very vague and subjective term. This is very dangerous when it comes to an exam setting. If you were to write instructions for a CSA actor, you would instruct him/her not to offer the relevant information until the candidate is using idiomatic phrases, as use of these is essential to what you would perceive as 'high level communication'. The obvious downside is that perfectly competent IMGs, who would otherwise be able to extract that information from a normal patient in their GP surgery, would find it difficult to do so from your simulator. You would view this as an unforgivable deficiency in the exam and fail the candidate.
    2) Your second point puts forth your question whether an acceptable standard of medicine can be be practiced without excellent communication skills. Many would agree this is a valid question. However, going by your definition of what constitutes excellent communication skills from the paragraph above, you have made the implication that someone who does not use idiom, or demonstrates an understanding of local culture is unable to provide an acceptable standard of medicine.
    For any CSA examiner or trainer to carry this bias is unacceptable.
    3) Your registrar did not receive any complaints for 2 years, also had an above average medical knowledge. To me, it means she has made a higher percentage of accurate diagnoses, also put in place better management plans, while successfully managing patient expectations.
    You would still rate her as only an average GP, as 'great' GPs, as we know by now, are those who use and understand idiom and thus can engage in 'high level communication'. The clinical skills seem to amount to zilch.
    4) You have been entrusted with the task of helping registrars in difficulty by the deanery. But at heart, you do not seem to believe they would make good GPs. I wonder what kind of assistance you provide these vulnerable doctors when you yourself are not convinced of their suitability. I suspect you just enable the deanery tick the box which says advanced help provided to trainee.

    High standards and excellence are already been shown by practising IMG GPs in the UK. The GMC is not very forgiving otherwise. The CSA exam, from Sept 2010 onwards has been warped by a prejudiced and narrow-minded definition of what constitutes 'high level communication'.

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  • Look At the appeal process of RCGP for £800.00
    Appeals can only be made in the following circumstances:
    1. There was an error in the calculation/collation of marks
    2. There was an irregularity in any part of the assessment
    3. There was evidence of prejudice or bias on the part of the examiner(s)
    No appeal will be considered solely on the grounds that the candidate wishes to challenge the academic judgment of the examiners
    Can somebody enlighten me how can anyone challenge these without video evidence?

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  • @ Dr.Mark Feldman
    Dr. Feldman mentions a very valid point here.
    GP consultation requires very good CONSULTATION SKILLS which we should not be confused with the proficiency in English Language. Certainly the proficiency in English language is important to master good consultation skills. Again we should not be confused ourselves with the proficiency and the accent. What matters is the substance of English Language and to have a clear accent which will not lead to misunderstandings.
    Now the question is just because one happen to be proficient in English Language would automatically possess good consultation skills. The answer would be no, I hope!!
    One would need to learn and practise consultation skills to be good at it. Otherwise, every citizen who born and bred in this country would be amazingly good at “consultation skills”. If that was the case good authors like Dr. Neighbour, Dr.Tate, Pendleton would have choosed to invest their hard work elsewhere. We also must be able to appreciate the fact that being a native and has been in the clinical practice many number of years would not automatically allow you to MASTER THE ART OF CONSULTATION SKILLS if you keep on applying the wrong set consultation skills throughout your career.
    “Language and cultural” reasoning does not go so far to explain why local black trainees who born and bred in this country fails ten times as their white friends. These are real issues with no plausible answers from the college.
    In my opinion CSA does not serve the purpose. If it does, I would simply accept the verdict and keep my mouth shut FOR THE SAKE OF MY PATIENTS leaving aside my grievances !!!!!!
    In my experience, the Fundamental problem with CSA is that IT FAILS MISCERABLY TO CHOOSE THE RIGHT PEOPLE FIT FOR THE PURPOSE regardless whether they are LOCALS OR IMGs. Many slips through the net.
    I suspect that is precisely the reason why the college is reluctant to keep any evidence of conduct of the exam.
    AS I SEE IT, THIS IS NOT ONLY AN ISSUE OF IMGs. THIS IS ALSO A PUBLIC SAFETY ISSUE !!!!
    I VERY MUCH HOPE AN INDEPENDENT INVESTIGATION TO THIS EXAM TO VERIFY WHETHER THE LATTER IS “FIT FOR THE PURPOSE” MUST BE CARRIED OUT IN ORDER TO SAFEGUARD PATIENTS,PROVIDE JUSTICE AND REASSURANCES TO THE TRAINEES AND TO THE PROFESSION”.
    LWT

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  • (1)Train the Trainer
    (2) Train the examiner that if you give max 6 marks to IMG with no x ( cross) you are undermining their ability and in fact is a PROBITY ISSUE at their end , so can be referred to GMC .
    (3) Train the actors - they should not hold cue until 8 or 9 th minute with IMG this is regarded as unfair treatment and opens for litigation .
    (4) CSA Candidate - practice with local graduates please.

    I hope this can be beginning of solution .
    Effect can be monitored in next exam in Feb 2013

    Good luck.

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  • I guess now examiners are going to give more crosses to justify giving 6/9. Nothing is going to change .
    Just keep practicing and pray that u get unbiased examiners on the day of yr exam.

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  • Achieving and maintaing the standard and patient safety are all fine.
    All the courses(MSC, PHD and Nursing) all have a pre assessment. Candiadtes are selected on the basis of the fact they are trainable.Deanery offered the training for clinical skills not for liquistic skill.

    We did not have any traing for linqusitic and we saw 36patients daily, lots of paper work and home visit. We spent time on eport folio.
    Now you are throwing away out. This does not happen any training programme to this extent.
    Few suggestions for RCGP and Deanery
    1. Discourage any new IMG coming into GPVTS
    2. If you take any IMG , make sure that you have 50% time spent in culture and language. Cinema, PUB, TV ect
    3. Whole 6/12 appoitment with liquitic skill like AE/Paed or Medicine
    4. Have the CSA at the entry and AKT at the time of Licencing
    5. Please give CCT for all the trainee who sat the exam after SEp 2010 on the basis of AKT and WPA
    6. Negotiated settlment as BAPIO prefers. Encourage RCGP to have good and meaningfull consultation with BAPIO and BIDA
    6. CSA looks much worser than MTAS which failed too

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  • We have received the letter from Prof Gerada and Dr Ben Brown(AIT commitee chair)
    Thanks for the letter and the reassurance.
    They are speaking still about patient safety, standard of care and AKT score
    Well we have to tell again that this is a exit process. If you want to maintain the standard that you have to have your CSA at the recruitment time or you should have designed the training according to the CSA need.
    Deanery says that Trainer should see more patient than trainer. Please go and see the practices that most of the patients are seen by the trainee and only often they seek help from the trainer
    Coming to the AKT; please do not confuse the figures. There is difference, not huge as in CSA.
    As some one suggsted earlier, you can have AKT as your licencing examination. This could be equvalent of KBA by RCP for medical trainee.
    No one is complaining about AKT now and only few people is struggling to pass the AKT weather it is UK graduates or IMG
    Anyway thanks for your letter Claire. Most of the IMG who fail the exam-CSA because they failed to be pateint centred and failed to get the ICE right
    Please get the ICE of the IMGs right and ofcourse pateint saftey is important. Do you think that all the doctors who passed the CSA before Sep2010 are posing great risk to the patient care currently. Why do you consider CSA is the only tool to maintain patient safety.What happened to your entry screening process, WPA, MSF, CSA, CBD, COT, ESR
    Do you think that 96% white female are safe doctor if the CSA is the right tool. In that case do you need a examination for the particular COHORT
    Please please understand that the distress and destruction caused by the CSA. This is all about CSA CSA CSA

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  • Can you make it anonymous

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