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RCGP accused of discriminating against ethnic minority candidates in MRCGP legal case

The RCGP has come under fierce attack at the High Court by an association of Indian doctors who say that ethnic minorities are being discriminated against and disadvantaged in their attempts to enter the profession.

Pointing to the wide disparity between the results of British and non-white candidates in the college’s entry exams, the British Association of Physicians of Indian Origin (BAPIO) says its members are being subjected to bias and race discrimination.

BAPIO is asking top judge, Mr Justice Mitting, to find the college in breach of its duty under the Equality Act to ensure that all candidates sitting its membership (MRCGP) exams are treated the same - however, the College vehemently denies the accusations.

Karon Monaghan QC, for BAPIO, told the judge: ‘The issue arising in this claim is the marked differences in the MRCGP success rates as between international medical graduates (IMGs) and non-IMGs and different racial groups.’

Focusing on the clinical skills Assessment (CSA) component of the MRCGP, the barrister said: ‘The most recent figures show, for example, an overall first time pass rate for UK graduates in the CSA of 91.4%. The equivalent figure for IMGs was 39.6%.’

She added: ‘The figure for white UK graduates was 96.5% but for south Asian UK graduates it was 84.8%.’

Miss Monaghan argued that the college’s Equality Act duties required it to take proportionate ‘positive action’ to put right any disadvantage or discrimination being suffered by overseas doctors in the examinations process.

She told the judge: ‘The college has failed and is continuing to fail to comply with the Public Sector Equality Duty (PSED) in repeatedly applying the MRCGP and, in particular, the CSA without modification notwithstanding that the discriminatory, that is to say disparate, outcomes are clear.”

The College had conducted no equality impact assessment when the CSA was introduced in 2007 and had maintained the MRCGP as a requirement for membership notwithstanding its obviously disparate results, she added.

The QC added: ‘The College has, because of their ethnic origin, treated black and minority ethnic (BME) candidates - both British graduates and and IMGs - less favourably than it treats white candidates.’

Miss Monaghan said: ‘Overall, BAPIO contends that the candidates’ nationality, national or ethnic origin, or colour, has had a significant influence on the outcome of their examinations.’

‘The only proper inference, therefore, is that the college has directly discriminated against IMGs and BME candidates.’

In court documents, the college denies discrimination or breaching its Equality Act duties and, along with the GMC, is resisting BAPIO’s judicial review challenge.

BAPIO’s written evidence to the court reveals that the college says it has repeatedly reviewed its membership criteria, both internally and externally, and takes multiple steps to ensure that BMEs and IMGs are in no way disadvantaged.

Those include inviting external observers to view the CSA and positive support for trainers who are sent on advanced courses to ensure that the correct methodology is used.

The college says that the differential in exam results could result from a whole raft of factors, including the quality of undergraduate training in different countries; the overall quality of candidates and the time elapsed between qualifying and sitting the CSA, which tends to be higher for IMGs.

An RCGP spokesperson told Pulse: ‘As the Court hearing in relation to this issue is taking place this week, we do not believe it is appropriate to comment at this time.’

The hearing continues.

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Readers' comments (41)

  • Many things can be explained away with differences in terms of cultural understanding and training for doctors that qualified abroad. However, I would be interested to see if anyone has an explanation as to why there is a difference in rates for UK trained applicants.

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  • @5:55 - could it be that their parents are different language speakers.
    Could it be that they are more likely to speak more than one language.

    We live in a multicultural culture, and people born and raised within the UK can have very different upbringings. Could it be that their different culture means that they are less able to communicate with the majority patient.

    Then there are more tentative links. Those from more ethnically diverse families are more likely to be pushed harder at school. My Indian mother did a lot more pushing than my English father. This means that medical school entrants/ graduates from those backgrounds have often achieved that through hard work rather than an underlying intelligence and brightness, meaning that in a setting where they work equally as hard as an adult their results are less good.

    For the same reason their balance of achievement may be different between book smarts and communications smarts, meaning that their is a bigger disparity between international graduates AKT and CSA results.

    All the above may be right, may be wrong; but there are plenty of reasons to explain the differences - it will come down to who has the better lawyers to make their point.

    I would like to know why there is a difference between male and female achievement in English GCSE - are they all sexist - are the exams fair but education sexist?
    Do we need positive action for short basketball players, small rugby players etc?

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  • Tom Caldwell

    Most importantly when do they expect the result to be made public ?

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  • Vinci Ho

    Has come a long way but let's wait for Mr Mitting's verdict first .

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  • It is extremely sad that there is such a huge difference in pass rates. It is equally sad and frustrating that no concrete corrective steps have been taken and that the things had to come this far. It is very frustrating to see trainees and their families in distress as well as the loss of these trainees from general practice.
    Credibility of the system needs restoring and hopefully,the legal action will put a positive end to this fiasco.
    An IMG GP Trainer

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  • Whatever the outcome of this JR, the College's Officers, CEO and the Director responsible for education and examinations need to be held to account for bringing the profession and College into disrepute. This was not done in my name.

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  • I am not sure re ''quality of undergraduate training in different countries '' . I would agree that methods of undergraduate training are different. For example IMG undergraduate trainees see real patients with real symptoms in undergraduate medical exams instead of talking to actors.

    I am not sure re ' the time elapsed between qualifying and sitting the CSA, which tends to be higher for IMGs ', this would actually be a positive point. More experience in other specialities makes you a all rounded GP which is needed now as more secondary services are being moved into primary care. GP with previous experience in areas like diabetes would be an asset.

    I am not sure re ' quality of candidates '. They are all selected through the same recruitment process.

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  • re quality of undergraduate training:
    - there is still a sense of medicine being more academic in some countries and vocational here. I think that the UK system prepares better GPs (I suspect a more academic system prepares better professors of medicine etc).

    re elapsed time between qualifying and sitting the CSA. I am sure that makes a difference. People 'learn' to be lazier as time goes by. This is often being more efficient but does not fit with preparing for an exam. I think a degree of maturity (1 or 2 years between F2 and GP1 years) actually helps candidates but 6 years trying to get on a surgical program probably does not help.

    With regards to quality of candidates I agree that has a part to play. The selection centre is far less accurate / comprehensive as the combination of the CSA and AKT. It also assesses candidates overall rather than trying to separate academic and communication skills. When I did it there were only 2 communications skills assessments. All passing selection centre is far from saying all are good enough to complete training - otherwise there would be no need for any more exams ever.

    In fact you could extrapolate that getting into med school is enough to get through, getting through medschool is enough to get through specialty training and so on.

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  • I am appalled by some of the horrible pathetic arguments that continue to be used by supporters of the csa to defend this 'exam.' imgs/ British ethnic minority doctors should not apply to GP training until they receive an apology for this dreadful situation

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  • If all this leads to a simplification of the farcical process in obtaining the MRCGP, future General Practice, if it has a future, will benefit significantly.

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  • Bapio: No matter what happens, I respect you from the heart. We need organisations like you who is there for the weak and the fairness... Thank you Bapio!

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  • RCGP can bring flimsy explanations to defend their actions. They will continue to deny the candidates right to have an open and fair assessment process by denying to video or provide second examiner during the examination process. They can do all that but truth will prevail one day. It takes only person in the inner circle to spill the beans. Then we will know what really went in these organisations behind closed doors. It is a matter of time. We just have be patient. God is watching us.

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  • What utter drivel

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  • Fact - UK trained GP's better than foreign trained. FACT - government rubbing hands in glee as future RCGP exam will be some dumbed down easy to pass paper so GP's from anywhere can have the presently prestigious RCGP. FACT - GP pay will plummet. Well done all, another coffin in our already buried coffin. Disgraceful. I would like to respond to all those who will now say I'm a racist...... I am not, I can just see the dark future that awaits for our once great profession and the substandard care patients will get. Shameful....

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  • 'another nail' was what I meant!

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  • lets await the outcome of the review, personally i find the attitudes of so many of the complainants sickening and lacking any self insight- I just wonder if I would want any of them as my GP.

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  • the comments part of these stories does seem to rapidly descend into an unhelpful trade of barely disguised insult and rudeness. Such a shame.

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  • @ 7.14 - before the CSA and AKT there were no compulsory exams to practice as a GP, MRCGP was optional - did that affects GPs adversely ? did affect GP pay adversely ?. No one is arguing to ' dumb ' down MRCGP exam. Follow good practices done by others - recording, 2 examiners for each station etc. There are many ' foreign ' trained consultants, GPs across whole of UK - does that mean they are getting ' substandard ' care ??

    We need thousands more GPs in near future considering secondary care services moving to primary care and other changes, do we expect all local undergraduate trainees move to GP training ??, we also need IMG trainees. Rather than stating '' UK trained GP's better than foreign trained '', we need to look into how to best train IMGs in the 3 years training programme, look into CSA assessment, use 2 examiners, video recording etc

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  • Who ever wins the case, what is the RCGP going to do to regain the confidence of all GPs? It needs to do what it recommends to all its trainees. Reflection on all aspects of the way it works by a group that is independent, respected and not part of the present or recent past leadership.

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  • @9.18 - undergraduate training is different from postgraduate training. In undergraduate training one needs to go through '' academic '' subjects like anatomy, microbiology, pathology, physiology etc to understand medicine and prepare for future postgraduate training. Otherwise without the basic medical sciences which are '' academic '' we would be producing hollow doctors. Would pts prefer to see a doctor with poor understanding of '' academic '' basic medical sciences and just good in communication skills ??
    Med school training is different from postgraduate training and cannot be extrapolated.

    In the US more emphasis is given on the rigorous postgraduate training than exams. Once you get through the initial screening USMLE and complete the training programme, the board exams towards the end are optional and one can still practice in that particular speciality without the boards. Thats the confidence they have in their training and not just relying on exams towards the end.

    And the AKT, CSA exams started recently, before that GPs could still practice without MRCGP. Were they not better GPs ??

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  • I came to UK in 1978 and at every job I was asked when am I going back to my country-I continued and when the time came in 1990s to get a training year for General Practice the same scenario appeared that because I spent 12 years as anaesthetist I was branded as rusty but then there was some one who recognised my talent in North Wales and gave me the break-I have never looked back-since then I got the certificate--trained as a GPwSI diabetes -participated in many trials and became a clinical lead having done a very successful fund holding carrier-after retirement I am still working for a CCG as the clinical lead and tutor--so the policy of discrimination has never changed --even as anaesthetist I was always given the difficult tasks which gave me a buzz--and the very people who thought I was rusty were asking for advice when they were stuck with a complicated case of diabetes--so the college rather than wasting so much money should own up to the discriminatory attitude and move forwards and let people give to the society the many skills the so called failed candidates have-just use the commonsense

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  • It is not possible to predict with certainty the outcome of a judicial review Though innocent with caveats,must be the odds on favourite
    All these young doctors passed the academically validated selection process and the similarly validated long cumbersome beauracratic work placed based assesment process
    Since all these assesments purport to indicate suitability to do the same thing i.e. consult in gneral practice the massive discrepency in their findings is astonishing
    So where does the racism occur, in the passing of the first two assesments when the candidate is given false hope, or in the third assesment when hope is extinguished
    I t is possible to predict with certainty that the verdict will not end the controversy

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  • IMG & BME Drs are doing WELL in AKT(Computer Based) and poor in CSA ( face-face based)

    It proves there is a Biased at the CSA.

    Biased occurs while Looking at the Drs ( His/Her colour, accent & verbal and nonverbal communications- by the Examiners(RCGP) and the Actors(Who are substituting-the Real patients) at the CSA.

    It can be improved, modified & the biased removed by Replacing the CSA from the Face to Face to the Computer Based Examinations as been done in many countries including USA which will be fair to the all concern.

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  • I am a UK born and trained GP of Indian/Pakistani origin. I passed every exam for the MRCGP first time and easily. I know IMGs and BME doctors that will watch films in their mother tongue - they will speak to me in their mother tongue, they will have a large cultural influence from their parental culture on their viewpoint and outlook. This is undoubtedly going to reduce their chances of passing an exam that is almost entirely based on British problems and in a British cultural context. What may be more appropriate is CSA exam that incorporates a reflective percentage of ethnically, culturally and even linguistically diverse scenarios, such as to match the current UK demographics.......but that's easy for me to say now that I've done my exams!

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  • Dr Mustapha Tahir

    What buffles me about this case is, why has any of the Royal Colleges never had to face this allegation? Or did I miss on the current affairs? Please let someone explain to me.

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  • @ 12.52 - '' cultural influence from their parental culture will undoubtedly going to reduce their chances of passing an exam '' - what utter nonsense ! is this exam testing parental cultural infuences ???, it seems like you are not very comfortable being spoken to in ' your mother tongue ' ?? and appears like being ashamed of watching films in ' your mother tongue '.

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  • I honestly couldn't care less that the non UK born IMGs are faring badly compared to their British counterparts because that can be easily explained away by language,cultural and educational differences.What is of more concern and something that hasn't been adequately explained is the presence of a significant gap between UK born white and UK born non-white graduates.I have yet to meet a single UK born non white graduate whose first language was not english.In fact quite a few of them,like their white counterparts, have been to public school.So using language in this case as an excuse doesn't wash.Assuming that these statistics are valid and not just a false positive there is a system bias somewhere.

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  • This comment has been moderated.

  • @ 1:09, its because the way training is structured. not passing the exams means the end of GP career while in other specialities one can still practice without the exams - as clinical fellow, staff grade, associate specialist etc.

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  • @ 1.13 '' I honestly couldn't care less that the non UK born IMGs are faring badly compared to their British counterparts because that can be easily explained away by language,cultural and educational differences ''

    ok but such a huge huge difference !!, then why is this not the same in US where there are as many IMGs as here ??

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  • @1:11. Your quote of my 12:52 comment is incorrect - taken out of context and doesn't even read correctly. I said ".....they will have a large cultural influence from their parental culture on their viewpoint and outlook. This is undoubtedly going to reduce their chances of passing an exam that is almost entirely based on British problems and in a British cultural context. ". Of course it is! Read 12:52 again - The influence of culture, language and religion plays a massive part in normal human interaction. General Practice is not just about the medicine is it. If you think it is just about the medicine then you are deluded and merely perpetuating incorrect advice given to the BME doctors.

    I also suggested that the default language for many of them is their mother tongue. Of course this will impact their ability to communicate where the default language is English. Paralinguistic cues, phrases, even saying things in a certain way confer different meanings. If you are used to doing that in Punjabi or Hindi then you will miss things when someone communicates using English - again please don't tell the IMGs/BMEs that its OK to just speak whatever language they want because that shouldn't affect your ability to communicate with the British people - that's utter rubbish.

    Also I am fluent - 100% fluent in Punjabi and Hindi/Urdu. I can read and write in my mother tongue to very good standard. I can mix culturally with Indian people absolutely fine - and I am not ashamed of my mother tongue or culture - but I am not willing to demand special dispensation for it when I live and work in Britain - an English speaking country with British values.

    Finally I think it appropriate to include a mix of problems and languages in the CSA - after all a white doctor is quite likely to need to speak to Punjabi/Urdu/Hindi/Polish speaking patient. The mix should reflect the current percentages of those languages in the UK - that will the exam more reflective of the British population not changing it so that British culture and the English language becomes irrelevant - because it's not!

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  • @ 1:11, I think you need to read Prof Esmail's CSA review in BMJ to get your view points clarified. The very huge difference in pass rates could not be just attributed to cultural and saying things in a certain way context.

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  • @ 2:08 - '' please don't tell the IMGs/BMEs that its OK to just speak whatever language they want because that shouldn't affect your ability to communicate with the British people - that's utter rubbish ''
    - does this imply - that IMGs should be advised to stop speaking their ' mother tongue ' or ' whatever language' so as to communicate here ???. This usually comes from a confused person who is not sure about his / her origins.

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  • There is no solidarity in this profession. Qualified members have idly stood by and paid their annual dues of £500+ to perpetuate the squalid regime and defend the indefensible. If BAPIO's case is upheld will the old guard continue to support a disreputable body? I left 10 years ago and have saved over £5,000 in todays money. My practice goes from strength to strength and I am free to choose whatever CPD support I require. There is no point in the RCGP.

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  • @ 1:111, An IMG or for that matter any person is perfectly capable of remaining connected to his / her cultural roots, speak their ' mother tongue ' and watch films in ' mother tongue ' and still be able to effectively communicate here. I agree some language nuances could play a role affecting a IMGs perfomance, but such glaringly huge difference in passrates needs another explanation.

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  • I passed my RCGP in second attempt. I am happy to be IMG, multilingual and have experience in different specialities. This is British exam and focuses on communication skills which is very important for GPS who are point of first contact for majority of the patients. Most of British graduates do well in this exam as they get lots of teaching on communication skills in their medical schools. IMGs should focus on their weaknesses during training. Emphasis should be on better training for IMGs rather than blaming college for being racist. I feel this exam does prepare you better for General practice. Again it's easy for me to say that as I have passed.

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  • Too many people are firing off an opinion here without any knowledge of the facts. Forget the CSA if you like -- what about the AKT? That is a machine marked test (blind to the ethnicity of the candidate) and the first attempt failure rates are 4.4% for white UK trained graduates and 65.2% for BME IMGs (nearly all Indian and Pakistani trained). Doesn't this suggest that many of these candidates, coming from a culture that has an imperfectly developed social health GP service, are not properly prepared for flying solo as a GP in the UK. We must stick to solid evidence. It is the safety of patients that we risk if we do not.

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  • I have seen numerus colleagues failing the exams, getting extensions into the training and than eventually passing it. I have never seen any Doctor being removed from the training due to constant failures.

    This just makes me feel the colleagues who have actually been out of traning despite several attempts and extensions in their training, were they really meant to be GPs?

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  • Please note I am not doubting those colleagues's ability as Doctors.....but this si not quite the same as GPs.

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  • Well, speaking as someone who recently sat (and passed) the CSA, i can genuinely say in think its a fair exam, I know i would have said that even if i failed. There was nothing in the exam which i would regard as unfair. Being a GP is about a lot more than clinical knowledge on its own. Perhpas the people who complain about the "racism" in the exam should spend some more time concentrating on their weaknesses and addressing these to pass rather than just moaning about it being "unfair" or blaming the colour of their skin. If i went to India or France or anywhere else to practice, i would exopect to have to adjust my styke and communication skills to suit the environment i was working in.

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  • The problem with the overseas drs argument is that the results in the face to face exams are very similar to the results for the machine marked AKT exam. This would suggest that the large disparity between the pass rates is not due to overt racism, but may be due to other factors such as lanquage.

    Where there is more of a problem is in the UK educated asian drs. There is a reasonably slim difference which may be due to racial bias on behalf of either the examiners or the actors, or equally it may be due to other factors (such as mentioned earlier with Indian parents being very successful at making their children owrk at school) - one just cannot tell. The ;problem with a face to face exam is that the suspicion of bias will always be there.

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  • isn't it odd? some people posting here and pass the exam and says it's fair - conflict of interest anyone?

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