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Gold, incentives and meh

Little improvement in international graduate scores on CSA, show new figures

The gap between the proportion of international medical graduates and UK graduates failing the RCGP membership exam has only slightly narrowed, results released by the college reveal.

The results, revealed in the MRCGP annual report, show that almost 60% of IMGs failed the clinical skills assessment between August 2012 and July 2013, compared with 7.5% of UK graduates.

The performance of IMGs showed only a marginal improvement on the 2011/12 intake, where 65.3% of IMGs failed, and this change was in line with a small improvement in results across the board.

The differences in failure rates between UK graduates and international medical graduates taking the exam has been the subject of a long-running row over the past year and is set to culminate in a judicial review hearing in April.

International doctor leaders said they were ‘disappointed’ that there was ‘no significant change’ in the results.

The results showed that 63.8% of IMGs from a black and minority ethnic background failed the exam, compared with only 3.5% of white UK graduates.

The scores for the advanced knowledge test (AKT) also showed significant differences in failure rates between IMGs and UK graduates, although not as stark, with 12.3% of UK graduates failing compared with 47.9% of IMGs.

UK graduated black and minority ethnic doctors’ scores improved - from a failure rate of 18.2% last year to 15.6% this year - but this was still way down on white UK graduated GPs’ results.

The judicial review into the differences in failure rates, instigated by the British Association of Physicians of Indian Origin and controversially backed by the BMA, is set to take place in April.

Dr Ramesh Mehta, the president of BAPIO, said: ‘We are disappointed that the story continues as before and there is no significant change. That clearly indicates that there has to be a change in the way assessment is carried out.’

‘We hope that once we have a positive result in the judicial review, we should be able to sit down with the college and look into a system of assessment that is fair and equitable.’

‘Patient safety and the quality of service remains of paramount importance to BAPIO.’

Dr Krishna Kasaraneni, chair of the GPC GP trainees subcommittee, said: ‘There still needs to be a lot of work to see why different groups and even medical schools have such different failure rates and this work needs to involve all stakeholders. The BMA would be happy to take part in that work.’

The MRCGP annual report also revealed that some candidates were allowed to retake the CSA exam because of ‘teething problems’ with the college’s new building.

It said: ‘Teething problems with the College’s new building meant that, because of unacceptable noise, some candidates sitting the November 2012 and May 2013 CSA were allowed an additional “non-counting” attempt subsequently.’


Proportion of graduates failing the CSA

International medical graduates59.80%65.30%59.20%
UK graduates7.50%9.90%8.20%
IMG (black and minority ethnic)63.80%68.10%62.10%
IMG (white)37.10%45.10%31.40%
UK (black and minority ethnic)15.60%18.20%16.10%
UK (white)3.50%5.80%3.90%




Readers' comments (37)

  • If the international graduates were as good as the UK graduates they wouldn't fail. Having been a 'patient' in the MRCP PACES exam last autumn I can testify that the international graduates in that particular exam were abyssmal - most of them were international too. It wasn't to do with language or colour, it was simply that they didn't know their stuff well enough. Bit shocking too to think they those particular candidates were already practicing doctors !

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  • So how do you account for a 3 fold difference in UK white vsUK qualified BME candidates?

    That is a huge discrepancy, and since these are trainees who have trained in the UK, demonstrates that there clearly is a racial bias against BME candidates.

    DOI a white UK GP from the old MRCGP system, which was far better than this crap is.

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  • "So how do you account for a 3 fold difference in UK white vs UK qualified BME candidates? "

    That is the question!

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  • Una Coales

    According to this latest CSA report, as a non UK medical school graduate of Korean ethnicity, I have a 0% chance of passing CSA and a white UK medical school graduate has a 96.5% chance of passing the same CSA. That in itself, suggests this exam may need tweaking?

    I agree with @6:41; in my opinion, the old MRCGP exam was far superior.

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  • its so sad to see the overt injustice against imgs carrying on in plain sight

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  • This comment has been deleted by the moderator

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  • Perhaps it is not racism, but simply a question of language. This is simply intended to stimulate debate.

    UK born White candidates usually are born into an English speaking household, and speak English for their entire life, so you would expect them to be fluent in communication in their native tongue.

    UK born BME doctors may well have been born into a household where English is not a first language, and their parents may not speak fluent English, though they will learn it from an early age. The majority will be as fluent as their colleagues, but due to cultural differences, their language skills will also be developed in their native language also, and there may be some whose home life is spent communicating in another language, and regional/cultural language may also have an impact during the formative years.

    If you were to look back and study GCSE English results and compare back to the exam results at CSA - would there be a correlation with those results, and those passing with grade lower than an 'A' being more likely to fail the CSA? This may explain the differences between the British born cohorts.

    As international graduates will not have English as a first language in the majority of cases, and although they may have even studied in English, the nuances of communicating in English, to English populations may not be a skill they would excel in compared to a British born candidate.

    I have met many excellent IMGs - but even when looking at the best ones, they often have poorer English language skills compared to their British born peers, but that is not unexpected. If you compare their GCSE equivalent skills it may correlate with their chances of passing, as would the number of years spent in the UK prior to starting training.

    It must be a disadvantage to any candidate to take an exam based so heavily in communication, when it is not your first language, and it is only really spoken at work. The rest of the time is often spent communicating in their native tongue with friends and family, and entertainment is often in native languages also.

    This problem will remain with the CSA while it is so heavily testing communication skills - however as a GP you will be needing those skills each and every day.

    Poor communication skills do need to be weeded out ideally prior to starting GP training at the selection centre stage. This will prevent good doctors wasting years training when they have a limited chance of actually passing the exit exam to become a GP.

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  • Out of interest do you get similar results at undergraduate level?

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  • Munna Bhai MBBS

    Story continues....
    Racism vs non racism
    People are comparing MRCP paces with Csa. Are they suggesting that in their opinion the 3 years GP training is a wasteful exercise? MRCP can be done without any training but CSA is done after 3 years training at par with white graduates. At the end of 3 years training, why do such differences exist and why has the college and the deaneries done nothing about it?
    If it were the case of white UK graduates would these bodies have kept quiet?
    When CSA was introduced, a few white candidates were affected and the RCGP refunded the whole fee and gave a free attempt in which all those failed candidates managed to pass. Is it not discrimination?

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  • @8:26am
    Please check the pass rates in USA/Canda
    For your knowledge their first language is 'English'!

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  • I myself was not born in UK - in fact I'm from oriental back ground, and I hope this allows me to debate this without being branded a racist.

    Over the years, I've seen many registrars come through but consistantly those that do not do well are male IMGs and of ethnic minorities origin. It's not just about the exams - I tend to get far more Pts being unhappy with the above sub group's consultation and management and we tend to go through more on our complaints meeting as well.

    We have to remember consultation skill is not just about the content of what is said but also how it is said. I still get far more complaints then my (dare I say) caucasian local born and bred colleague who has softer approach to communicating then me, despite our management of patients being very similar.

    If we are to be judged by our ability to serve the local population, I'm afraid racial difference in communicating skill is not something we can ignore and pretend it doesn't exist.

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  • @Anonymous | 25 February 2014 8:26am

    I don't think you can pin it all down to language differences.Almost every UK born BME that i have met speak english as their first language and are often not very fluent in their ethnic tongues at all.It strongly suggests racial discrimination but from a biological/evolutionary perspective that's to be expected.We're heading towards informal apartheid where all coloured patients will see coloured doctors and white doctors will see white patients.Two informal councils will arise one setting standards for white doctors and the other for the coloureds

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  • what is astonishing is the number of times strange excuses are employed by various people to explain a very unfair situation.
    You cannot change who you are. it is quite clear some people have some very troubling ideas about doctors of certain ethnic minorities before they have uttered a word. Give a candidate a chance. if you already have a conception that he is ethnic, male, img etc and that means he wont do well in this 'exam' then nothing that candidate does is going to be good enough for you. my question is how effective is the entrance examination to enter on the vts scheme. or are you going to blame that on the poor candidate as well?

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  • I note people are ignoring the AKT scores. 12.3% for UK graduates vs 47.9% for IMGs is pretty stark don't you think? How do people explain those differences in a computer delivered, anonymised exam? Not heard any accusations of racism for that. Can I suggest that the reasons for the discrepancies are clearly complex and multifactorial? How many of you have friends or have met patients who have complained bitterly that the doctor they last saw couldn't communicate or be understood? I thought we were trying to weed those physicians out?

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  • The trainees are being failed from selection process until the CSA by various bodies whose responsibility was to make sure the training and assessment is as fair and robust as possible to produce safe competent GPs towards the end of the process.
    This whole affair of training and assessment is in shambles wasting millions of public money. Not to mention the wasted time and psychological distress endured by trainees who were released from training.
    Some people who are being paid tax payer’s money to ensure their money spent with responsibility seem to have failed in their job. I will tell you why,
    1. They failed to select the trainable candidates to undergo the VTS training
    2. They failed to recognise the deficiencies early and put remedial measures to ensure rest of the training will prepare the vast majority of trainees to be successful in the CSA exam or they are taken out of training early.
    3. They endorsed progression annually by ARCP panels giving trainees false reassurance until the disaster strike in CSA.
    4. They are still in denial about their shortcomings and continue to waste tax payer’s money without taking appropriate steps to ensure tax payers get their return on their investment. Again not to mention the impact on the demoralised and broken group of doctors trying find their way back in their lives.
    We all do mistakes. That is human nature. S..t happens. That’s life.
    But what I cannot understand and condone the short sightedness and arrogance of some people. They should have the common sense and humbleness to reflect on what went wrong and have the courage to put things right.
    Battering the failed trainees will not help to improve the selection process.
    Battering the failed trainees will not help to improve the VTS training.
    Battering the failed trainees will not help to make the assessment process robust.
    Battering the failed trainees will not help to produce safe , competent, motivated and compassionate doctors for this country.
    Therefore wake up and do something positive to address the core of problems rather than use trainees as the reason for the problems in the system. Do it least for the sake our patients and children future.

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  • Dear Anonymous @ 08.26am and 10.18am
    Thanks for your very constructive comments.
    Unfortunately I could not agree with you all entirely.
    1. English is not spoken by household in many BME cases. I thought same as the cause of the difference in the pass rate at CSA. However ethnic minority outperform white in Language now days. Please read the article as an evidence.
    White British Children Outperformed By Ethnic Minority Groups
    PA | Posted: 22/03/2013 08:48 GMT | Updated: 22/03/2013 09:08 GMT PA. These children came from same background, taught in English and did the exam in English.
    Also, Language factor does explain the difference between white(IMG) and Black IMG. I suppose majority of white IMGs are from EU. They were not standardised by the IELTS/PLAB before training. GMC really is concerned about these doctors and works on their language. These doctors outperformed the black and Asian IMGs at CSA
    3.Communication and caring
    These are very important in all profession including animal medicine. we need to explain the things clearly to the pet owner if you can not speak to the animal. Recent studies showed foreign nurses are better than UK trained nurses here.NHS’s foreign nurses ‘best at caring’
    Sarah-Kate Templeton, Health Editor Published: 12 January 2014
    4. Complaints. It seems IMGs male get more complain than locals. We need to explore further. we need to get more data on it. In my experience I found mixed picture. During my ST1/GPVTS_ I do not have any idea about CSA and very poor consultation skills. I did not receive any complaints in 6 months.
    During my ST3 , I was preparing for CSA and had very good experience.
    One IMG female Registrar who was sitting CSA 9th time, she did get any complaints. She was released from the training after 9th attempt failure.
    Myself did get 3complaints and failed the CSA by 10marks. One Nigerian girl , she got 6 complaints and she passed CSA with 91.Finally one Asian female IMG, she did get 3 complaints and passed the CSA with 74.
    5.NHS workforce and Level of communication.
    How much English we can expect from the IMGs. We can not expect them to speak like native. The whole world is closely connected. English , as an international Language is spoken in 1000s of ways. People should understand each other clearly.
    Now, AE in crisis of doctors and Health ministry is meeting with BAPIO next month recruit senior doctors from India. Do you think what is percentage is going to pass CSA styled communication. If they can not find doctors from India, can you get all well-English speaking doctors who were trained here from tax payers money and left to USA, Australia and Canada.
    Government says( Deputy PM), without immigrants NHS would not function.
    So passing IELTS, PLAB and selection process should be enough to check the communication.
    5.Purpose of the CSA
    In real practice ,if patients come with multiple issues, all GPs know CSA does not work. Most patients want all issues sorted rather than CSA singing for one issue.
    In conclusion, CSA was designed for good purpose, but unfortunately, it is not weeding out bad doctors only, unfortunately good doctors as well

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  • frequently trainers who have not done the CSA are employed to 'train' candidates. the candidate fails. a story is made about the candidate and the candidate is blamed. Many strangee excuses are employed some of which are on this thread Is this fair? Why are we not asking more questions about trainers? why blame the trainee?

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  • The point made by Anon 11:59 does need acknowledging. IMGs also have a 400% worse failure rate than white UK graduates on a computer-marked MCQ. This cannot be rascist and suggests there are real differences in knowledge & performance between the two groups. I agree the training process is completely failing them by not addressing this at an earlier stage. Are annual AMKs needed?

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  • The following was pointed out in a previous thread (I believe it was Una Coales)
    Chinese/SE Asians UK grad AKT pass rate is 95.7%, the highest and surpasses the white UK grad AKT pass rate of 90.8%, yet the Chinese/ SE Asian UK grad CSA score drops dramatically to 77% vs 96% for white UK grads. This information is readily available on the RCGP websife under MRCGP annual report 2010-2011. The conclusion that AKT mirrors CSA is incorrect.

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  • If someone has got the time and can get the cooperation, I would love to see a study looking at score at first CSA attempt V risk of GMC hearing/ GMC sanctions etc. Maybe total number of complaints.

    As someone who did particularly well in the CSA (non-white british graduate) I am pretty sure those same communication skills are often the difference between a slightly upset patient and mega-complaint.

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  • @7:46 different patient populations have different needs. Sometimes doctors may be requested to do things which are against good medical practice. If they refuse, a complaint may ensue. I hope your 'study' would include such factors. Do u assume that every complaint made against every doctor is legitimate ? Are you interested at all in the doctor's perspective?

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  • editor please can you keep this prominent on the website. the CSA is a very important issue and many people need to read this

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  • To 24 February 2014 6:07pm
    I am sorry, but you are ill informed, this scandal comes amid a furious row over the recent report of the Professor Aneez Esmail, a leading academic and GP, has accused the RCGP of "refusing to accept there is a problem" with the exam and trying to brush concerns about possible bias "under the carpet". His six-month review found that ethnic minority doctors trained in the UK were four times more likely to fail the exam at the first attempt than UK-trained white candidates, while ethnic minority doctors trained abroad were 14 times more likely to fail.

    In the GMC report, Professor Esmail and co-author Professor Chris Roberts say they cannot "confidently exclude bias from the examiners in the way that they assess non-white candidates.

    It is fundamentally wrong, that if a trainee cannot communicate as a snob, he or she is deemed to be unfit. You have to consider the fact that the majority fails by one mark, an obscured anomalies, they are not there to become surgeons but General Practitioners. CSA should involve real patients and not hired actors... etc... Equally, the culture of the old - boys network seems to be the ugly hidden factor behind this scandal. Have you ever heard that a Trainer or a Program Director of a Deanery being monitored for their competency level to train?
    Please check the facts before making judgement:

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  • @ Anonymous | 01 March 2014 11:14am

    You are lacking knowledge, and this is dangerous when you then proceed to express your opinions as fact.

    'In the GMC report, Professor Esmail and co-author Professor Chris Roberts say they cannot "confidently exclude bias from the examiners in the way that they assess non-white candidates.' - The fact they cannot confidently exclude bias, is not proof of bias in any form.

    ' Have you ever heard that a Trainer or a Program Director of a Deanery being monitored for their competency level to train? ' - Again a glaring error - as now all GP Trainers and all Program Directors are required to complete the Post Graduate Certificate in Education as an extra qualification to ensure high levels of teaching standards will be maintained.

    It is very sad that some trainees were accepted for GP training but are not able to pass the exams after multiple attempts - but a minimum standard needed to progress is required, otherwise why bother having any exit exams at all.

    If you are unable to communicate you will always struggle. Good candidates will always pass any exam.

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  • @1March 2014 2:04pm 'the Post Graduate Certificate in Education as an extra qualification to ensure high levels of teaching standards will be maintained.'
    slight problem with what you have said it has made virtually no difference for the pass rates of imgs and british ethnic minority doctors.
    Putting you head in the sand about issues that Aneez Ismail raised will not help either.
    You can continue the present approach of blaming the trainees but its not the trainees who developed the entrance exams into the VTS schemes nor did they devise this CSA 'exam.'
    An exam without real life patients, with an impossible appeals process and persistent refusal to have more than 1 examiner in each room unlike other exams.
    If you feel that despite this, this exam is fair then there is something greatly amiss?
    I am truly disturbed by the strange arguments people persist in employing to defend this CSA.
    If one is an img think very hard before going on the VTS scheme- it could be very painful. BAPIO must take measures to dissuade people from joining VTS schemes as it appears others do not care the slightest about img welfare

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  • BAPIO needs £200 000 in legal fees to fight their case in the courts. It is such a shame that one has to spend £200 000 to seek justice. You wonder if one has to spend that sort of mega money to seek justice for obvious injustice, what it says about the justice itself?

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  • @1049 2nd march 2014
    hit the nail on the head. it is a case of put up with injustice because one cannot afford the other form of justice i.e. a high court battle with huge amount of fees. if it weren't for bapio nobody would have that kind of money to engage in this essential fight for justice. you have seen the silly arguments people use to support the csa agenda. bapio still needs support

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  • Others might say that the silliest arguments were from BAPIO.

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  • @02 March 2014 9:21pm

    throughout this thread and others in pulse many have explained quite well why the csa is a poor exam.
    your post is a vital clue to the actual reason why bapio and poor imgs are having such a horrible time. Individuals such as yourself are not interested in the truth! You have already decided who you feel should pass and fail. so in many respects there is no point in having the exam is there?
    Can you give an example of an argument from Bapio which you think was silly and why?

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  • CSA assessment for clinical knowledge is appalling. While other Royal Colleges such as RCP is testing knowledge and clinical reasoning, CSA is testing counselling skills. We R DOCTORS!!! Not Social Workers!!! People can pass Myotonic Dystrophy in PACES but not able to pass Carpal Tunnel Syndrome in CSA. It's a joke!!! Even local medical student can pass CSA if he/she talks well...

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  • Anonymous@ 7.29AM
    I failed CSA 4times. I still think that your comment is not fair. There is clear and huge difference between Carpal Tunnel Syndrome or Myotonic dystrophy in terms of pathology and a patient with CTS/MD. I know the difference, but under pressure , I automatically switch to your mentality and fail

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  • It would be interesting to see which examiners mark down the IMGs consistently. If such examiners are found, their examining skills need to be compared with rest of the examiners who do not demonstrate such tendency. It is only fair such examiners to be excluded from the examiners pool and make them accountable for the trainees they have failed unfairly.

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  • Based on my experience , CSA exam is not a good exam to differentiate good and poor candidates.Its sensitivity and specificity appears to be very low. So many bad candidates slip through the net.

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  • The saga of CSA is never ending story unless some realistic and fruitful steps taken by RCGP to correct bias, deaneries to train the trainers properly and catch struggling candidates early in the training with more input to improve their communication skills. It is a misfortune to blame the IMGs, when they have achieved to get a training post and rubbish them at the end of the training saying they are useless. Everyone talks about communication, but without actual 'COMMUNICATION'. Is there a study comparing examiners performance wrt to IMGs and local graduates and their pass rates! It would be interesting to know the facts, if they have one!!

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  • I just sat my CSA exam. I concur with @10:28. In our deanery, east kent, we have had those who have slipped through the net. If I was a patient i would never go to these so called RCGP approved " future" GPs. They are plain rubbish but don't know how they've managed to clear CSA. Probably being an empathetic actor, they've "shone".
    Common fact that NHS is failing esp GP Land being hit the hardest. I have no hope in this new crop from my deanery ( not certain of you all ). Govt restrictions, patient demands, target issues can only worsen this much loved job.
    you may call me a pessimist but that's also the reality. Sugar coating the fact will not hide the truth.

    - Tj Ans

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  • Recently I have heard regarding a IMG doctor working in paediatrics as a staff grade for couple of years after passing his exams applied for CCT, went through the whole training and has now been appointed as a consultant in paediatrics and is now helping to improve local nephrology services.

    Could we imagine anything similar and accomodating with RCGP. Its a shame that good quality trainees only because they cannot be 100 % on the CSA day have left with no hope of practising as a GP again after training for 3 years ! their would be valuable contribution to General Practise is lost forever !

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  • The CSA is a ridiculous test. I sat it in December 2014 and I do not feel it relates to everyday general practice. The only facet it 'actually' tests is your ability to communicate. I grant this is, quite obviously, an important quality in any Doctor, but then to look beyond the AKT, PSQs, CbDs, COTs, mini CEXs, MSFs and clinical and educational supervision reports and judge the CSA as the definitive parameter by which a trainee is deemed competent is ludicrous - especially when such trainees have practiced successfully for years as competent GMC accredited Doctors.

    The RCGP is digging it's own hole for the future of general practice in this country.

    I hope I pass my CSA but being a British born Asian, I cannot be so sure.

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