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Independents' Day

MRCGP 'fairest' means of ensuring safe GPs, court hears

The MRCGP exam is the ‘fairest and most robust’ means of ensuring that unsafe doctors are not allowed to practise, the High Court has heard.

The RCGP and the GMC have been defending themselves in the High Court against claims that ethnic minorities are being disadvantaged and subjected to racial discrimination in their attempts to enter the profession.

The British Association of Physicians of Indian Origin points to the wide disparity between the results of British and non-white candidates in the College’s entry exams and wants a full equality impact assessment carried out.

Both the College and the GMC hotly dispute BAPIO’s claims and are resisting the judicial review challenge.

Peter Oldham QC, representing the College, defended the CSA component of its membership exam as ‘the fairest and most robust’ means of ensuring that unsafe or incompetent doctors are not allowed to practise as GPs.

Attacking BAPIO’s case as ‘bad on the facts, however formulated’, the barrister said there was not the slightest evidence that any candidate had scored lower than he or she should have done by reason of examiner bias.

Far from having a closed mind or failing to focus on equality issues, the College had commissioned a vast amount of research to understand the reasons for differentials in performance in the CSA.

‘On the contrary, all the evidence is of an organisation that is greatly concerned with differential pass rates in the CSA’, added Mr Oldham.

BAPIO did not dispute the absolute need for the competencies tested by the CSA, a test which was ‘of the utmost importance to public health’.

And the QC said: ‘The CSA protects the public against the very few who ultimately fail it…it is therefore an exam to ensure that unsafe or incompetent doctors are not allowed to practise as GPs.  That plainly is a legitimate aim”.

Urging Mr Justice Mitting to dismiss BAPIO’s judicial review challenge, Mr Oldham said that the formulation of the CSA was non-discriminatory and ‘shows all the hallmarks of objectivity and careful thought’.

Disputing claims that the CSA discriminates against overseas medical graduates, who have more than double the failure rate of their British-educated counterparts, the barrister said there were a host of possible reasons why that was so.

Foreign graduates had to pass particular tests to embark on GP training - known as IELTS and PLAB - and Mr Oldham said it is the college’s stance that they are ‘too undemanding’ to necessarily put them on an equal footing with UK-trained doctors.

There were, said Mr Oldham, stark contrasts between the quality of medical training in various different countries and overseas graduates often faced a longer gap between qualification and taking the CSA.

The difference in exam results between overseas graduates and British-educated medics was a phenomenon seen across the entire medical profession and Mr Oldham said there was ‘nothing statistically aberrant’ about CSA results.

John Bowers QC, for the GMC - which has overseen the College’s curriculum since 2010 -  insisted that the overall design of the CSA was entirely consistent with the Public Sector Equality Duty laid down by the Equality Act 2010.

Mr Bowers said the CSA is designed to test candidates’ rapport with patients as well as their clinical, professional, communication and practical skills.

And the QC told the court: ‘The GMC considers that the CSA fulfils its standards.’

Urging the judge to dismiss BAPIO’S challenge, Mr Bowers added: ‘The remedy sought by BAPIO of an equality impact assessment would not add to the exhaustive research which has already been carried out and the alternatives to the current model of the examination are not viable.’

He told Mr Justice Mitting that the GMC’s role was ‘strictly limited’ to ensuring that the college’s entry criteria met proper professional standards and it was not involved in selecting, appointing, training or supervising those who carry out the CSA.

Mr Bowers added: ‘Examinations are inherently difficult matters for a court to intervene in; there is no perfect system and normally the court will not interfere in what are essentially matters of academic judgment.’

The reasons for under-performance of some candidates were ‘multi-factorial’ and it was no part of the GMC’s ‘purely reactive’ role to develop or propose changes to the CSA.

Before the GMC approved the College’s curriculum and assessment processes in 2010, it had worked hard with the College to seek to identify causes of the differences in pass rates and to iron out any possible discriminatory effects, said Mr Bowers.

However, the QC said: ‘The only relevant substantive point to emerge from this research is that no-one has concluded that the CSA is in fact discriminatory. Much of the research concluded that the differences in pass rates could not be attributed to race discrimination.’

BAPIO’s criticism is focused on the Clinical Skills Assessment (CSA) element of the College’s membership (MRCGP) exams.  With less than 40% of international medical graduates (IMGs) passing first time - compared with over 90% of UK graduates.

The judge is expected to reserve his decision on the case until a later date.

Readers' comments (25)

  • Tom Caldwell

    11:22 pm I suspect the breakdown of the GPs complained about would need to be assessed to support your assertion. I thought the demographic was older male GPs having higher rate of complaint which would work against your assertion of this being related to the CSA. As to the plummeting public confidence I again wonder if a hostile political agenda and press may offer a more likely explanation.

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  • There many GPs who are practising safely without MRCGP

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  • All GPs who qualified pre CSA need to be assessed again with current AKT and current CSA to make sure they are safe and competent

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  • Please correct me if I am wrong - if there is confidence in CSA to weed out unsafe and incompetent drs, then there is this MAP membership of college by assessment process which needs submission of portfolio and no AKT or CSA, so wouldn't this be considered a back door entry ?

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  • 1122 - I think we know that complaints and public confidence in GP is less to do with the quality of general practice and more to do with the media.

    I think people trying to use poorly defined associations between the exam and anything bad in the world distracts from the bigger picture and makes the rest of the world think they are just trying to discredit the exam because they did not pass rather than truly believing there is a racist element.

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  • @ 9.39 '' Perhaps we should cancel all exit exams in all specialties '' - all specialities do not have exit exams. For example in Anaesthetics, part 1 and part 2 exams are done around ST2-3 and there is no exit exam at ST 7-8.
    In post graduate training more emphasis should be given on rigorous training rather than just exams towards the end. That one day of the exam could be good or a bad day for the candidate

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  • The latest CSA is designed in such way to leave out of the net IMGs, period. I doubt BAPIO will win the tribunal simply on racial basis. Bear in mind, on the eye of the law you have to prove it "beyond any doubt" and I do not see it happening.
    There are a few important elements which make CSA unfit for purpose and as e mean for certain "exclusion":
    1- The stubbornness of RCGP to use only one examiner
    2- The denial of video recording for purpose of proper appeal
    3- The lack of proper specific CSA feedback for each CSA station
    If RCGP are open and fair why they do not allow video recording?
    RCP uses two examiners for the equivalent exam and the assessment of each often varies from clear pass to clear fail. That is a fact not fiction.
    Whatever arguments CSA defenders use a CSA examiner with 10 minutes set up consultation with often badly instructed actors cannot judge assess better than the average assessments of clinical supervisors, GP trainers and joint clinics not forgetting patient's feedback and questionnaires. If a candidate (like myself) has passed and completed all other components of GP Training and been signed off as Competent for Licencing and marginally failed by CSA and kicked out of training I strongly believe there is something fundamentally wrong with this exam

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  • 9.39 & 1.22 - but the exams are needed to progress up the ladder to the next stage. If you fail to get MRCP, FRCS, the anasthetic qualifications, or the qualifications of any of the other royal colleges you simple fail to climb the training tree and move sideways to another speciality (often GP!) or go to the sub consultant grade. General practice is coming from the other end and has no exams for progression but an end exam (better than no exam as was the situation 35 years ago) but arguably not better than the other colleges who have longer training periods.

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  • I finished GP training last year and reflected on this a lot. I am an IMG myself.
    I feel the problem is not with the exam but with those candidates who often enter GP training for the wrong reasons.
    They somehow perceive it as an "easier" option and with a better lifestyle "seeing coughs and colds and prescribing paracetamol 9-5pm". Unrealistic expectations!
    They hope that as GPs, they will have more time for their families and hobbies.
    This is especially the case with mature consultants or staff grades (often IMGs) who decide to change their career to become GPs.
    These are the ones that usually really struggle. They plod along the first 2 years with their big egos and then suddenly realise that GP training is much more formal and complex than they originally thought it was and really struggle. They tend to find it hard to accept requests from nurses, especially under stress situations.
    Their ego does not accept failure,especially because they compare themselves with peers back home who are settled in a completely different health system (evil facebook!) and after the first failure they fall into this frame of mind that there must be a conspiracy against IMGs, the exam is racist, this and that and that they "must" pass on the next sitting life or death situation meaning they lose focus on the exam itself.
    We all have our worries. After all, there is a lot at stake but I think they press the "panic button" too early and find themselves trapped, unable to get out of panic mode and find comfort in mingling with trainees in the same situation which only makes matters worse by trying to get the validation that the problem is with the exam and not with them. How many times did I hear that?
    They do role-playing together,sharing the same inaccuracies in management or being robotic and learning a script. There are no scripts in the CSA!
    There were 2 white male British graduates that failed their first CSA attempt in my batch and everyone was looking at them with disbelief. How could this be? They didn't take much notice of this and passed their next attempt and did not make any fuss. Why should they?
    I felt that both my VTS scheme and the deanery were extremely informative and supportive and do NOT think this exam is racist.
    The greatest glory in living lies not in never falling, but in rising every time ...

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  • I passed CSA in my third attempt. I was short of 2 marks in my first 2 attempts. Same actress did 2 different scenerios and demanding 'something' which was not clinically needed so refused to do/discuss. End result 3 and 4 crosses on those stations. Luckily in my third attempt she was not there and I passed! I even told my trainer that I dont want her in my day.
    If the result of an exam depends on actor/actress and their mood then we can only pray to God for his mercy.
    I feel for my friends who left GP land because of the CSA, they are very good doctors but I dont have the courage to call them. Time is a great healer and I am sure they are happy with what they are doing now.

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