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Gold, incentives and meh

RCGP reviewing whether MRCGP exam is ‘fit for purpose’

Exclusive The RCGP has drafted in consultants to carry out a ‘comprehensive review’ of its controversial MRCGP exam, which will look at whether the assessment is ‘fit for purpose’.

It is also looking at whether ‘fairness to candidates’ is sufficiently considered at ‘all stages of test design and delivery’, following controversy around the gap in pass rates between white and BME candidates.

The college said that it is undertaking the review now because the exam has been running for 10 years and is ‘therefore at an appropriate point at which to evaluate its content and structure’.

It is also ensuring that the exam is in line with the GMC’s revised standards for postgraduate curricula, published in May.

The Health Professional Assessment Consultancy has been appointed is to review the MRCGP assessment – including the Applied Knowledge Test (AKT), the Clinical Skills Assessment (CSA) and the Workplace Based Assessment (WPBA) - and suggest potential changes.

According to a paper presented at this month’s RCGP council meeting, the review is expected to include answers to the following questions:

  • Is the current programme of assessment fit for the purpose of a postgraduate medical license?
  • Are there emerging evidence-based assessment methodologies that the RCGP should consider to ensure that the MRCGP remains fit for purpose and adaptable?
  • Does the programme of assessment meet the requirements of the GMC’s Standards for Curriculum and Assessment Review, including the proposed General Professional Competences?
  • Is fairness to candidates sufficiently considered at all stages of test design and delivery?
  • Are the current standards appropriate to ensure patient safety?
  • What enhancements to test development, standard setting and quality assurance methodologies might be appropriate?

The MRCGP has come under fire in the past on a number of issues. In 2015, Pulse reported that the BMA had concerns over perceived high fees.

Meanwhile GP leaders have previously called on the RCGP to look at reforming the training process, with former college chair Professor Clare Gerada questioning the necessity of the CSA aspect of the exam.

And the exam has been the subject of a long-running dispute about the differences in failure rates between UK white and BME graduates and international medical graduates, which sparked a judicial review hearing instigated by the British Association of Physicians of Indian Origin (BAPIO) in 2014.

The review ruled that the exam was lawful but the judge stressed that the RCGP needed to ‘eliminate discrimination’ in the MRCGP and tackle the differences in failure rates between white and non-white medical graduates sitting the CSA.

 

 

Readers' comments (38)

  • Cobblers

    It would be better if the review was

    "If the RCGP is fit for purpose".

    COI am not and never was a RCGP doctor. I had the option of taking the exam but at that time it was not a de facto pass requirement for GP Training.

    I did not like what I saw in the early 1980s. I like it even less now.

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  • RCGP is suffering with a massive case of unconscious bias.

    CSA is easy to pass if you stick a hot potato in your mouth.

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  • This comment has been moderated.

  • What purpose?
    Is it to demonstrate a knowledge of academic papers, and thought, in relation to the field of primary care
    or
    Is it to validate the ability to diagnose,run a practice,and hit sufficient targets to maintain financial viability
    Bear in mind all CSA consultations are by definition incompetent, since no record of any is ever made.The MDU would decline to defend any consultation along CSA lines, if it were with a real patient

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  • It isn't. Go back to summative assessment and MRCGP if people want to bother. This was all about RCGP taking control.

    DOI: MRCGP(2008) no longer a member as it delivers little of benefit I can see.

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  • Much that I do not think the MRCGP is fit for purpose. I can't help but feel the GMC being involved brings in a political element where they will try to water down standards to allow non medics to attempt college exams.

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  • Jo Smit, you may have a point there.

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  • agree, not fit for purpose. huge subconscious bias in CSA

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  • You pass CSA if you know to 'act' and prepare to fail if you apply some sense as you do in normal practice.

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  • Interesting development and an indicator that the 'college' knew that thair CSA exam stank all along. (And no I'm not an IMG who wants justice for being taken for a ride and having my life ruined by these cowboys).

    Rather than being obsessed with being in London, if the RCGP relocated to a more sensible accessible location like the midlands they wouldn't have to pay such a huge mortgage on their prestige building? Then perhaps exam fees could come down and the feeling that the RCGP exploits its trainees, is self serving and doesn't give two hoots about its members or having hugely expensive dysfunctional exams which aren't fit for purpose in the first place,might change.

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  • Agree with Jo Smit - I have concerns about the MRCGP and particularly allegations of subconscious bias (DOI - I'm white and I passed it) but I also feel that at a time where the traditional GP role is being taken on by other clinicians (nurses, PAs) that we should be ensuring that a newly trained and qualified GP is at a sufficiently high standard to justify that role and salary.
    I would have concerns about moving back to a purely workplace based assessment system, as it is too easy for struggling trainees to be pushed through as "that's the easy thing to do". This will only become a bigger problem as our workload increases and intensifies as we will have less capcity (time, mental etc) to tackle the difficult trainees.

    Also as private providers increase their foothold in GP I wonder whether they will also take on any roles in training, and I would imagine that in that environment this could be an issue as well.

    I'm glad they're looking at it at the very least but I worry that the pendulum may swing too far in the other direction.

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  • Vinci Ho

    (1) Allowing more non-medics to become doctors and then GPs seems to become an inevitable reality . This government must bear the responsibility on all the consequences, whatever they are.
    (2) One examination to judge is always subjected to controversies. Unconscious bias was the legal diagnosis from court on MRCGP examination. Inaction to, at least , provide an alternative is in fact continuing to erode the credibility( whatever is left)of the college .
    (3) Funding more education programmes to help new MRCGPs for further development in general practice is more essential. Learning never stops after completing an examination.

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  • It is standard practice to do a review. The GMC is involved because they set all standards for postgraduate exams.
    There certainly maybe unconscious bias acting but it does not explain why certain ethnicity does less well in machine marked papers. That is the crucial question.

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  • I suspect the examination needs to be made easier to help facilitate the recruitment drive for GPs and what better way to do these by announcing a ''review''

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  • Tom Caldwell

    Fitness for purpose after it's been going a long time. Probably standard practice. But a headline that does not engender confidence in RCGP.

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  • I think it is a fairly good assessment but it is difficult..and expensive

    I worry about the unfairness of it when they are shipping in unqualified GP's from Europe in countries where they dont have VTS schemes and haven't done exams.They are bypassing the system and seem to be able to practice without the MRCGP.

    Also there plenty of nurse practitioners who are practising on undifferentiated patients with a fairly minimal course....

    It all seems a bit unequal, unfair.

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  • Well if non-medical professionals can practice but those who marginally failed CSA can't, what can possibly be considered as a reasonable purpose achieved by the system? How is the fitness for purpose going to be assessed we'll probably never find out. Hasn't RCGP quite clearly already failed it's purpose by all methods of measurement? Don't we already know what the result of this assessment is going to be? Oh well, it really looks like nobody is genuinely touched by any common sense. Failing MRCGP by 5 marks makes you incompetent to practice as a GP while non-medical professionals are sought after in order to put things right. Is this not in itself a system failure?

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  • There is no doubt that it's a biased exam.it depends on your colour ,sex and how good is your acting.

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  • Complete shambles - always has been and likely always will be - only remarkable in that RCGP and GMC presume themselves to be standards of quality but are infamous for only maintaining their own accelerating dysfunctionality.

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  • Maybe a review allows them to charge even more! That wine cellar won't fill itself and the cardies may be forced to actually do some clinical work if they're not sitting in London weaving baskets and planning "training" whilst we all sink ever deeper...

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  • The CSA is not a perfect exam but is better than nothing. It is pretty straight forward - 1 problem per 10 minutes, minimal examination as the patients are actors and no notes to record. It is very expensive, however. The concern, as mentioned previously, is the push for GPs from the EU, some of whom have little or no postgraduate qualifications or evidence of basic competence. I worry about clinical standards and the knock on effect this could have for the profession as a whole.

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  • IMGs here in Canada who haven't done a GP training definitely practice differently in some cases overinvestigating over treating. So I am also concerned about the GPs from the EU who have not done similar training coming to help.

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  • Well in the view of RCGP, EU doctors are obviously more suitable to practice straight away as they undertake a full 3 months period of training in a boot camp before joining. Fully trained doctors marked competent for licensing by RCGP trainers however are not, if they don't pass CSA. This says it all.

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  • Does it really serve the patient safety principle to discard from training 100 doctors every year and then go round looking for non medical professionals to fill the gap? If anything, this seems to be the very purpose. Is CSA fit for it? It certainly is.

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  • Would you really think, as a college, that you truly deserve to have the privilege of being considered a popular speciality when you treat some of your trainees the way you do? A very good example of what goes round comes round I suppose.
    Do you really think it serves the patients safety principle to discard from training 100 doctors every year and then go round looking for non medical professionals to fill the gap?

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  • Im also wondering why the RCGP have commissioned a review from a consultancy company of UK academics who have registered their company in Singapore rather than the U, no doubt to avoid tax. Corporate Social Responsibility? Who apparently cares. I just hope RCGP members consider where their membership fees flow to as well as come from.

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  • we need consultation if RCGP is fit for purpose. I have zero faith in RCGP.

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  • CSA is color coded.
    Alas! they cant see our colour for ASA theory exam.

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  • 100 discarded doctors every year - by the way, a small number. How many patients does a GP see every day? At least around 20 and supposedly the GP only works 5-6 sessions a week, that is approximately 60 patients weekly and 2700 yearly. If you have 100 doctors who despite training and resources spent by RCGP to train them, don't eventually become GPs, that is around 300000 patients added every year to the waiting club. Over the past 10 years it's 3 million more patients waiting longer to get a GP appointment if lucky enough to be registered with one .Go and tell those patients who struggle to get an appointment with their GP that 2700 or even 3 million of them is actually a small number. This is RCGP policy. Patient safety? Hmm...

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  • In answer to the hospital doctor who thinks an average gp sees 20 patients a day-the reality for me is 36 patients in clinic, plus visits and phone calls. Administration on top of this.
    Nearer 40 patients seen per day .

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  • Vinci Ho

    My curiosity and ignorance.
    Does anyone know whether the college ever had a non Caucasian(if that is the politically correct label) president or chair? If not , anybody's bet there will be one in the future?

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  • For the past 5 years I have been witnessing how the most knowledgeable GP trainees have been discarded from training by the biased CSA exam and on the other hand how the poorest trainees are passing this exam with flying scores!

    I have witnessed the CSA exam in USA, where they mark fairly and everyone with the basic knowledge and a bit of good practice can pass that on their first attempt, as they deserve. Whereas in UK, the best GP trainees have failed CSA after their 3-5 attempts despite having best preparation and following the best consultation skills/guidelines and changing strategies which never changed their marks! How is this possible?

    My question is why RCGP has not been showing any flexibility in incorporating the feedback of many experts/doctors to rectify this dilemma and save the whole profession?

    Why such a huge number of good doctors who were trained in this country and are familiar with British culture are discharged from training with no option left. RCGP does not seem to be touched.

    Why RCGP has decided to fill the created gap in workforce by bringing GPs who are trained in Eastern Europe or India rather than using those British doctors already trained within the system in order to alleviate the situation?

    All in all, I am requesting RCGP to find the quickest way to rectify this disasterous exam and find a fair way to bring back those doctors to the GP profession as our country now is in the highest need of them.

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  • 20 patients a day,if only.40 or more,with additional,visits,results,letters to code( 30-50)'results to decipher 30 or more,practice admin,staff issues,business issues,phone calls and queries.Way way to much work to manage.I wonder why recruitment is so dire!!!!!!!!!!!!

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  • Another concern is that when it comes to medical defence relating to practice of non GP professionals the responsibility comes back to the partners to respond to the complaint. So we are responsible for our own practice but also for supervision of allied professionals who should be working independently. All this at a time when workload is already unmanageable and there are fewer and fewer GPs to carry the burden

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  • Its very unfair that a doctor who has spent 5 years studying medicine and then worked as trainee in NHS at different level for 5 + years, who has showed continues progress and marked competent to work as GP on work place based assessment, is deemed unsafe just based on doctor getting just 1 mark less in acting based CSA exam.The doctor is denied oppertunity to work in trained speciality labelled unsafe while physician assosiates with no medical degree and just 2 years training and no MRCGP can work in general practice.Is patient safety not compromised with PA' s working in general practice?

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  • Una Coales. Retired NHS GP.

    I commend BAPIO (British Association of Physicians of Indian Origin) for taking the RCGP to High Court over the acting CSA exam. A moral victory was needed to expose how failure to control unconscious bias may have resulted in the huge disparity between white and non white doctor pass rates, which had not existed when real patient video consultations were used to assess doctors for the MRCGP exam. It is incredulous that the acting CSA exam is still operating in the 21st century. IMO Martin Luther King Jr would be turning in his grave.

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  • As a GP very near retirement I have the advantage of historical perspective even though I am not currently involved.
    My concerns are more about the content of general practice than the method used to assess it. The exam has been obsessed with the consultation for decades, quite appropriately two decades ago, but (though still of vital importance) less central now that the content of primary care has shifted so much. Dealing with complexity is now the most challenging aspect of primary care and the importance of the GP role as conductor of the diagnostic/therapeutic/caring orchestra needs to be moved to the epicentre of the MRCGP exam. This involves holism in the traditional sense, but with the addition of ensuring the unified working of the other health and social care professionals to avoid gaps in care, wasteful overlap or, worst of all unknowing clash of incompatible interventions. The challenge of therapeutics has never been greater, and cannot be totally relegated to pharmacists or nurses or hospital specialists. The only person with the complete therapeutic score on his/her desk with a knowledge base to evaluate it is the GP. And this means that GPs need to have a much more extensive knowledge of therapeutics than has previously been necessary. Team working has always been a characteristic of quality primary care, but teams are now bigger, more diverse and often multi-sited and multiagency. Taking global responsibility for the patient, especially those who lack capacity, is essential to avoid fragmented care, and the GP is the obvious and most appropriately skilled person to take this role. But so doing requires formal continuity of care, which is under threat from part-time and casual working health professionals. Organisation of practices so as to provide continuity of care in the face of discontinuity of staffing is one of the most pressing problems. It is achievable but requires sophisticated practice management and an ethos of joint working. Out of hours care has become a black spot in primary care, a casualty of underfunding, privatisation and the loss of GP direction. Quality has suffered, and the lack of investment in academic study of out-of-hours care means that there is little evidence that can direct the organisation and provision of service. Yet the use paramedic response teams in this area leads to waste, unnecessary hospital admission and poor quality holistic care. General practice must aim to take back control of this area of care, and the membership exam needs to recognise its importance.

    These are difficult times for general practice, but if we are to preserve our discipline, which is capable of providing high quality patient-sensitive, effective and efficient care at remarkably low cost, my successors need to focus on the areas of care that generalists are most suited to provide. We must also ensure that the high standards of the MRCGP exam are relevant to the job description of sort of GP needed in the future.

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  • Everyone knows its just a money grab from BME, especially BME international graduates by all Colleges. That simple. Nothing more nothing less. This has been going on for decades with every college!! How else would the college get funded with ever dwindling membership? Many leaving country and many leaving the membership inside UK.
    I still remember a quote from a Female hospital colleague, " He was my reg, when I was SHO. He knows a lot more than anybody I knew in this whole hospital. But he failed and I passed. I know they make it difficult for you guys to pass."

    Make few rules - reduce the exam fees, none of the fees from exams goes to Colleges for any expenses other than trainees, reduce the pay, no luxury biscuits, no natural mineral water - (just tap water is enough), no five star treatment or accommodation paid for for GP examiners, stop hiring Royal stage actors for exam - everyone would pass first time. Stop the exams being a business opportunity and profit based exercise for colleges.

    If you want to test communication skills and English language ask candidates to take IELTS - standard English test all over the world.

    CSA exam has no real world bearing either for communication skills or medical knowledge. CSA is biased exam. So is AKT. Asking non-english native speakers to do a english reading game with complicated sentence structure and asking them to differentiate between false negatives and untrue non-positives and shorter time limit. Not actually a test for clinical knowledge in true sense.

    Just a game.

    P.S - I took exams with 3 different royal colleges. Above info is from real world personal experience.
    Thanks Una for remaining in touch with this wretched world.

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  • The review has been going on for more than 7 months. Anyone have an idea when this review will be out ?

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