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Porter: RCGP must 'acknowledge there is a problem' in exam row

Exclusive BMA chair Dr Mark Porter has criticised the RCGP’s response to the independent review into potential racial bias in the MRCGP exam, claiming that the college ‘must be brought to realise’ it has to address the controversy.

Speaking at a dinner event at the annual conference of the British International Doctors’ Association in Burnley over the weekend, Dr Porter said the RCGP’s response to the findings of the review by racism expert Professor Aneez Esmail was ‘not good enough’, and it was ‘stunning’ that such a ‘respected author’ could not exclude the possibility of subjective bias.

Dr Porter’s comments mark the strongest criticism yet from the BMA over the controversy, after an independent review of the MRCGP by Professor Esmail found ‘significant differences’ in failure rates between different ethnic groups in the CSA exam.

Professor Esmail’s full report - commissioned by the GMC - concluded ‘the method of assessment is not a reason for the differential outcomes that we have described’, leading the RCGP and the GMC to claim that it had exonerated the clinical skills assessment.

But a separate paper by Professor Esmail - published in the BMJ at the same time as his report to the GMC, and based on the same research - concluded that that ‘subjective bias due to racial discrimination’ in the CSA may be a cause of higher failure rates for UK-born ethnic minority and international candidates taking the exam.

A furious row then erupted as Professor Esmail warned that evidence of racial bias must not be swept ‘under the carpet’ and accused the GMC of misrepresenting his research - a claim the GMC strenuously rejected.

The RCGP, which is currently facing a judicial review brought by international doctors seeking to declare the exam unlawful, has consistently denied that the exam is in any way discriminatory or biased.

Dr Porter told doctors at the BIDA conference dinner that the BMA would push for meetings with the RCGP to ‘get to a place where they acknowledge there is a problem’.

He said that both the GMC-commissioned review and the BMJ paper had ‘the same authors, the same data and pretty much the same conclusions if you read them’.

‘Though it is possible to hide behind the different use of language to say one exonerates the RCGP while the other condemns it, I am not sure either goes to that end,’ he said. ‘The point is, there is an issue there to be dealt with.’

Dr Porter said the BMA’s own study over the past six months had made recommendations ‘around ensuring the CSA includes a diverse mix of cases, that examiners are drawn from a diverse population, and that candidates should receive more feedback’.

He added: ‘We’ve drawn this up before finding out that Professor Esmail was making similar recommendations, which is good because his recommendations are based on solid and objective data whereas ours were based on a discursive examination of what was happening around the various royal colleges.’

Dr Porter said: ‘One of the reasons the RCGP finds itself in the firing line is because they have such good data that people can look through them and find statistically valid data for analysis, which cannot be said of all royal colleges.’

But he added: ‘Essentially, we have said what we are doing and what BAPIO are doing, but we have a royal college here that must be brought to realise what the problem is.’

‘Significant questions remain unanswered and putting out a press release last week that basically says “there is no case to answer here, move on and don’t look at us and we’ll get on with defending the Judicial Review” – that is not good enough.’

Dr Porter referred to a previous speaker’s mention of the fiftieth anniversary of Martin Luther King’s ‘I have a dream’ speech, and ‘tremendous changes that have taken place in some ways but not others’.

He added: ‘It is stunning that we can get to 2013 and find that a major royal college is running examinations from which a respected author can conclude that we cannot exclude the issue of subjective bias.’

The BMA would meet with the RCGP to discuss the issue, Dr Porter said: ‘We are trying to help the RCGP to get to a place where they can acknowledge there is a problem and have something done about it rather than saying “we have been exonerated” and we will be taking that forward in the next week.’

In a separate statement released yesterday, the BMA announced that Dr Porter met Professor Esmail last week.

Dr Chandra Kanneganti, a member of BIDA’s executive committee and a member of the GPC, said: ‘I’m happy that Dr Porter spoke about these issues. He also spoke about other issues affecting international medical graduates and we would like to thank him for highlighting these issues more than ever before.’

A statement from the RCGP said: ‘It is our job to ensure that, through a fair process, all the doctors who qualify as GPs meet the requisite standards for ensuring safe patient care. That is what the public expects of us, and that is what we deliver.

‘We take equality and diversity issues extremely seriously and we already take comprehensive steps to ensure that the exam is fair and equitable to all candidatesand are currently reviewing the recommendations in this area from Professor Esmail’s independent GMC-commissioned review of the MRCGP.

‘We have been well aware of differential pass rates for many years, as is the case with all medical specialties, and have worked very hard to understand the possible reasons for the differences. We are currently in contact about this matter with the BMA, the deaneries and the Academy of Medical Royal Colleges.’

‘We are extremely surprised that while Professor Esmail’s official GMC investigation found no evidence of discrimination in the RCGP exam, there are now media reports suggesting that the exam may be discriminatory after all.’

‘In the official and independent GMC report, Professor Esmail found that “the method of [the RCGP] examination is not a reason for the differential outcomes that…have been described. The CSA examination is based on a well established pedagogy which is internationally recognised and used widely in postgraduate examinations”.’

“He also said that: ‘Our observations suggest that international medical graduates are treated exactly the same as British graduates’, going on to say: ‘Lack of preparedness’ of international medical graduates ‘may be an explanation for the differences between the two groups’.

The High Court will next week hear an appeal by the British Association of Physicians of Indian Origin (BAPIO) against a decision to exclude the GMC from its judicial review on the CSA. The hearing will also announce the date of the full judicial review.

 

This was updated at 16:14 on Wednesday 9 October

Readers' comments (40)

  • Bma loses my subscription and membership once more

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  • Tom Caldwell

    Does the BMA acknowledge there is a problem with its response to threats to the NHS and our profession from the government? Do they acknowledge their response is simply not good enough? The RCGP response does I agree fall below what you should expect , but given the impotence the BMA displays against this government I think they are equally guilty of a charge of being not good enough.

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  • Unfortunately I doubt if any of this will lead to anything meaningful for IMGs

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  • @11:18 I presume you have two memberships! How can BMA lose you 'once more' if you've already left before, unless of course you keep coming back because you realise your mistake.

    The author of the report said 'subjective bias due to racism could not be excluded' - end of. Please feel free to actually read the reports before commenting next time!

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  • The CSA has become an embarrassment to UK general practice, a festering sore that will not go away....

    From an international point of view it is a discredited and toxic brand, the only rational solution is to scrap it and come up with something better (preferably blinded to creed and color). The RCGP is just delaying the inevitable if they think they can get away with this one.

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  • @12:16
    I don't know whether you managed to pass or fail this exam but can't agree more with your comment.
    You have summed up the whole issue so nicely.
    The toxic brand as you have mentioned is so precious for RCGP that they can't dare to scrap it.
    Its like the cigarettes which atleast carry a warning.
    I have spent 4 precious years of my life- 3 on completing everything and the last, on loosing whatever I had gained in those 3 years including my family, self confidence and so much money on all this. Atleast, the RCGP should stop all these people making a business out of all this by charging so much on courses.

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  • @12:16

    You summed it up very nicely.
    Those 13 actors and invisible examiners pick up something which has not been picked up previously by thousand of patients, hundred of senior colleagues in hospitals and practices.
    My 3 trainers ( all Caucasians ) couldn't find the reason for two failed attempts after numerous joint surgeries and video consultations. The only advice was to speak more 'british'.

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  • 12.45 and 1.24, sorry to hear about your woes. I did in fact pass the exam on my first attempt but I'm a white male so it wan't particularly difficult.

    The only thing I can suggest as consolation is that the market for medical care is now globalized. I'm sure something will come up if you fancy a move to a brighter climate with less damp, interminable grey skies, where your skills will no doubt be welcomed.
    (Tip - try New Zealand, I really enjoyed my time there).

    Unfortunately for the RCGP the more they invest in defending it, the harder it will be to do the honorable thing but you can't polish a turd so it will have to go eventually. This will be a bit too late for general practice as a major recruitment crisis is already well underway.

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  • BMA has been selectively active in past . I have been BMA member for 10 treats but stopped this year as I found them very unhelpful
    RCGP has lot questions to answer . Having gone through this highly subjective bias exam it is high time they accept the faults

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  • @1:47
    Thanks for your kind words.
    I have considered Australia and New zealand but it will take some time for me to get my confidence back.
    I'm sure once you become a trainer, you will do a much better job than some of the present trainers who have no clue about this exam.

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  • Times have changed. When I was an undergraduate and we had examinations on which promotion depended, most of the students who failed were convinced one or other of the examiners 'had it in for them'. There was never any appeal process, and no one ever complained about this. No one went through our examination papers to tell us in what areas we were deficient; and the only check on bias was the presence of an external examiner, who we all thought was there to ensure that our professors were not too lenient..

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  • I agree with Adrian.
    Good old days. Examiners did their job well. No one had to question their judgement because almost every candidate felt it was fair. Only a fair few failed and there were valid reasons for that. Statistics for MRCGP is staggering. There is something really fishy about this exam. RCGP attitude and resistance for video the exam is astonishing and almost a sign of accepting the guilt. Good luck chaps.

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  • The BMA & GMC have been silent and therefore complicit for far too long. The RCGP should never have been allowed to assume responsibility for the licensing exam. They are only interested in milking trainees to pay for the unnecessary new HQ in Euston.

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  • Do people really think the examiners are racists? Get real!

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  • anonymous@ 6:20
    How do you know they are not?
    Most of the posters here have suffered at the hands of these CSA examiners and role players and hence know for sure there is some element of direct discrimination. It seems you have not got any sympathy for those who have suffered due to this exam and are defending the RCGP as if you are one of them!!

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  • I am astonished at what Dr Porter says. I will be leaving the BMA (after 34 years)in protest. He clearly has only read the headline and not the evidence.

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  • Anonymous @ 620, if you think there is no racial bias in the CSA exam then you should read the BMJ article more carefully. Bias is a very difficult concept and no doubt we are all guilty of succumbing to it in one way or another. The problem here is the fact that the bias in the RCGP exam leaves some candidates, from a specific and well defined group, disadvantaged. Having gone through exactly the same process at every stage as their peers, they are then left out at the last minute with no qualification or career in front of them. That can not be right.
    As for Adrian Pointer's comment, times really have changed. The sooner the RCGP understands this, the better it is.

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  • I agree with Alok. This is a dirty game between GMC, RCGP, deaneries, trainee practices and the affected trainees where everyone is trying to blame the other but no one seems to do anything. The only agency which has stood up for the trainees is BAPIO with BPDF, BIDA, BMA providing some outside support.
    These agencies should help BAPIO to fight against RCGP for this noble cause.

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  • @Alok Tyagi, You say, 'Having gone through exactly the same process at every stage as their peers'. That is an incorrect statement and flawed assumption. IMGs complete the majority of their medical education overseas, where general practice may not even exist as a discipline. It's not even something they grew up with. For some, foundation and specialty training is their first exposure to GP. That's not racism. It's fact.

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  • @6:31

    Just because someone doesn't share your view, it doesn't make them wrong, a racist or an RCGP supporter.

    If you read the published report, it states there is no evidence of racism. However, in the subsequent BMJ article, the author appears to change their mind.

    Either way, there is no conclusive evidence of racism.

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  • 'Do people really think the examiners are racists? Get real!'
    You don't have to be a fully signed up member of a fascist organization to collude in institutional racial discrimination, ''the collective failure of an organization to provide an appropriate and professional service to people because of their colour, culture, or ethnic origin"
    The RCGP are going through their own Stephen Lawrence Inquiry and they are not exactly excelling themselves.

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  • The sad thing is, if the RCGP had simply held their hand up and said, 'we are sorry, we got this wrong,' they would probably have been exonerated by now and the RCGP exam would have been made fit for purpose. In stead they have elected to defend the indefensible which has just made the whole thing a whole lot worse.

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  • What is interesting in the data is not the difference between IMGs and British trained candidates (where you would expect the British trained trainees to do better as their degrees in essence prepares them for the CSA) but between British trained white trainees and their colleagues from ethnic minorities. The difference here of more than 10% year on year difference in pass rates speaks volumes. How does the RCGP account for this difference?

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  • Looks like college on the verge of discovery -
    'CSA gene' - codes for CSA style consultation skills traits.
    Presence - pass with flying colors , trainee preparation advice - don't bother.
    Absence - formulaic consultation , borderline skills -advice - hmm , you can try.

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  • Anonymous @ 840 the IMGs undergo exactly the same selection process for the GP training program. They then go through the same training, the same AKT, the same WPBA & the same ARCPs. So how come the significantly disparate results in the CSA exam ?
    Even if you forget about the IMGs because,
    'IMGs complete the majority of their medical education overseas, where general practice may not even exist as a discipline. It's not even something they grew up with. For some, foundation and specialty training is their first exposure to GP',
    can you explain the significantly disparate results between 'white' and 'BME' UK graduates ?
    I guess you would say that is because they are culturally different ? Exactly ! That is what bias is ! Switch the actors and the examiners to reflect the cultural make up of the United Kingdom today and then look at the results of this exam. The recent analysis in the BMJ correctly concludes that you can not exclude a bias based on race in the CSA exam as it is being conducted since 2010. It's a fact.

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  • Change CSA. RCGP please this not working. Pleeease listen before you are caught pants down.
    Written paper(essay) and viva will solve the problem.

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  • @12:16

    I can only wish Dr Claire Gerada was reading your comment....

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  • BMA

    Too little, too late mate.
    Oh, I have an idea.... Why don't you tag team with BAPIO and fight together??

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  • BMA has been pretty useless tackling with major issues affecting doctors, let along BME doctors. I left BMA a couple of years back after I realised it is not fit for purpose. I would be better of with nobody than with the BMA as I know they won't be there for me anyways when I will need them. What a useless trade union.

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  • It looks like BMA has realised RCGP is going to lose the cause....

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  • Edoardo Cervoni

    RCGP (and BMA) may have to reconsider their mission, vision and strategy.
    At the present, my humble opinion is that they lack of a clear scope and that I cannot see many colleagues around passionate about their memberships.
    When being a MRCGP or a FRCGP is seen as being “financially” advantageous or a “must”, there is something wrong. The only thing I would advocate in the medical field are passion and dedication. The nearest you are to the pity “cash”, the worse it gets (pretty much everything).
    As far as the exams are concerned, I would suggest to "breaking down" the assessments during the training years.
    Furthermore, after many years of clinical practice, I can confidently say that non-clinical skills and values are grossly under-estimated.

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  • @09 October 2013 8:40pm
    “IMGs complete the majority of their medical education overseas, where general practice may not even exist as a discipline. It's not even something they grew up with. For some, foundation and specialty training is their first exposure to GP. That's not racism. It's fact.”
    How would you account for the astonishing discrepancy of the pass rate between “white British” and “BME British” candidates. Surely you will have another FLIMSY EXPLANATION like the above to defend the latter. GET REAL BUDDY!!

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  • The real issue is that doctors should be safe to practice and be able to communicate with their patients.

    Sadly many doctors are not safe to practice, nothing to do with their medical skills but the fact that we are told over 900 of them have criminal offences

    Re communication, many foreign doctors speak English, but not in a clear enough manner that we can understand them. Many foreign doctors have have very strong accents and speak far to fast fro us to keep up with their ramblings.

    I would also agree that there are some fantastic foreign doctors from all around the world. It does leave me wondering what happens to the born and bread English doctors that are becoming a rare breed?

    Everyone wants the best of care from the best doctors so please let us make sure any doctor working in Britain is nothing but the best in their field!

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  • @shurleea Harding,
    I agree that every one deserve best treatment. I am IMG with postgraduate qualification not only from Britain but Overseas.
    I have worked in different seniority levels in UK. I have seen every complication and practice written in the books and some not written in UK and people responsible are both "BEST BRITISH" doctors and Bad IMGs.
    I was never asked by any gp in saw in UK like I am expected to ask?
    Get real. British Medicine is not best, perhaps it is run by IMGs.
    UK is only country with F1, F2, Speciality Doc, Staff Grade, SPR, StR, Associate specialist, subconsultant, clinical assistants. so much discrimination in same grade.

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  • Shurlee Harding :
    These doctors with "strong accents" and who "speak fast and rambles" are deemed fit to practice by the GMC by way of PLAB. Which is Professional and Linguistic assessment board exam. Their "accents" and "rambles" are assessed thoroughly in the linguistic component.
    So might I suggest you write to the GMC and raise your concerns about the PLAB exam as to why it has allowed those doctors "with strong rambling accents" fit to practice.

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  • Dear Shurleea harding
    please kindly learn to write English properly. Lot of fundamental mistakes in your comments.

    Many foreign doctors HAVE HAVE very strong accents and speak far TO fast FRO us to keep up with their ramblings.(it is TOO fast FOR)
    born and bread English (it is BRED not BREAD!)

    regards

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