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Independents' Day

Time to scrap CSA exams

Dr Kamal Sidhu

It seems to be an annual ritual that we make a bit of fuss for just a week or so around why more BME doctors struggle with MRCGP exams, and then the issue is largely forgotten again.

This year, the unabated disparity between the pass rates of BME candidates and those of white candidates has been brought to focus by the threat from the British Association of Physicians of Indian Origin (BAPIO) to launch another judicial review. Meanwhile, the trainees continue to suffer and the differential attainment continues to be explained by officials under the garb of ’complex issues’.

It is not only those who fail who suffer. Most trainees, including those subsets who have high success rates, understandably spend a disproportionate amount of time worrying about passing. The exams are too expensive, with the costs running into thousands of pounds, which places immense strain on trainees and their families.

We continue to haemorrhage GP trainees at a time when the profession is on its knees due to lack of staff. There is untold hidden damage of discouraging doctors from taking the exam - who would have otherwise chosen or switched to general practice. It also continues to be a slap in the face of any aspiration of a fairer society amidst largely superficial talk about equality and diversity.

The RCGP has consistently failed to address the fact that BME people who are born in the UK and trained in this system continue to perform poorly. When alternative formats to MRCGP have been suggested in the past, it has been argued that this would be a compromise to patient safety, when there is no evidence that the new format has resulted in safer or better doctors, especially when we have thousands of our colleagues who qualified before this format was introduced and continue to provide excellent care.

Those at the helm of the RCGP appear happy to accept a lack of GPs, and surgeries and out-of-hours services collapsing. Little has been achieved since the BAPIO brought court action against the RCGP, although the judge clearly said that something needs to be done.

Let's hope it doesn't take another prolonged judicial battle for some concrete action


On the contrary, the gap in exam pass rates has only widened. It is simply baffling and disgraceful that our future BME generations will have a higher failure rate under the existing system, despite being born and educated in this system.  

Calls to look at alternative exam formats have gone unheeded, but it really is a serious crisis that directly affects patient safety. The BMA has made some noise about this, but despite so many being directly affected by the issue, the bonhomie continues.

Any GP trainer can tell you about what is wrong with the current format. Aspirational topics with little relevance to real general practice, such as complex statistical questions focused on memorising guidelines and an overemphasis on communication skills.

The solution is not difficult. It is time to scrap the existing format. Even the former chair of the college, who had termed the issue as ‘noise in Pulse and on Twitter’, has called for the Clinical Skills Assessment to be scrapped. We need to rely more on real-time feedback, trainer assessments and options such as simulated or video surgery-based assessments.

The bar at which MRCGP exams are set isn’t reflective of the day-to-day routine of general practice. To make matters worse, general practice is the only speciality where we have a final exam. Unlike in other specialities, GPs can't practise unless they pass this. 

This is a huge impediment to recruitment that requires urgent review. This is the least we can do for the sake of our patients, who are faced with either being unable to see a GP at all or lengthy waits to do so.

The exam format needs an overhaul not only to create equity of opportunity between BME and white candidates - but to reduce the risk to patient safety from the understaffed GP workforce.

So it is due to the risk to patient safety that this format needs an overhaul. It is at our own peril that we continue to ignore a major issue that has knock-on effects on recruitment and retention.

Let’s hope it doesn’t take another prolonged judicial battle for some concrete action.

Dr Kamal Sidhu is a partner and trainer at Blackhall and Peterlee Practice and New Seaham Medical Group; chair at South Durham Health Community Interest Company; and vice-chair at County Durham and Darlington LMC. He writes in a personal capacity.

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Readers' comments (31)

  • ‘Those at the helm of the RCGP appear happy to accept a lack of GPs, and surgeries and out-of-hours services collapsing.’
    The complacency and perfidiousness of the self-satisfied, huddling in their Ivory Towers, has brought the medical profession in this country to it’s knees (and in turn, medical care will crash and burn).
    But we will be saved by the oncoming legions of physicians assistants, nurse graduates, pharmacists, homeopaths etc. Ha!

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  • Time to rename the CSA = COMMUNICATION SKILLS ASSESSMENT. Which begs the questions why does the RCGP need to run this the HOME OFFICE does it better, IELTS, LIFE IN THE UK ETC.

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  • Communication skills are only a small part of being a GP. For sure, some would argue these are important but for the profession to thrive we actually need a diverse workforce. That means recruiting people who have a head for business, people who want to do minor ops, people who have an eye for data crunching and audit and yes, people with high emotional intelligence. The current CSA is throwing a lot of decent doctors on the scrap heap at a time when UK GPs are on their knees drowning in a sea of demand. The CSA discriminates against anyone with any form of communication deficit, be that through cultural and language issues or autistic spectrum characteristics, this is terrible and needs to be called out besides which most doctors get better in the first 5 years of practice as they hone what was learned as a registrar and adapt it for the less forgiving real world of front line NHS care. Scrapping the CSA is not a demand for low standards, rather recognition of the wide ranging and rapidly changing needs of our profession.

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  • Title should read Time to scrap RCGP
    I have worked for 25 years as a GP without ever becoming a member, my patients and colleagues haven’t been the least bit bothered. The Royal college is and always has been a complete irrelevance.

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  • Show the RCGP’s AKT, CSA and WPBA to an American Family Physician and they’ll laugh in your face. The exams are crap, the GP “curriculum” is crap, the training is crap, trainers are crap, the list goes on.

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  • GP training has evolved. Initially no training at all. There was an apprenticeship model. Then there was the Trainer "Certification of satisfactory completion". You only failed that if you inadvertently slept with the Trainer's wife. This was eventually replaced by either passing the MRCGP exam or the Summative assessment exam (for the thickies). Eventually this merged into the MRCGP. Videos of a surgery were sent to the exam board. Seemed a good idea initially but became increasingly artificial as the candidates devised cunning ways of deceiving the exam board (get a friend in as a pretend patient etc). CSA was then conceived. Initially served a useful purpose but has once again been distorted by cunning candidates learning crafty techniques to get the actors to spill the beans. The process has become increasingly artificial.

    It is an unfair exam and "BME" doctors are at a disadvantage.

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  • The communication skills are oversold outdated models to further someone's CV, get someone paid so they do not need to see patients and their RCGP ambitions. It has very little bearing on day to day practice. Most patients are very happy to see a doctor who can give a quick diagnosis and treatment without all the time wasting fluff. Are you affected psychologically? How about telling me your home life etc? Respecting patient's privacy is also a skill.

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  • .. am not sure why it is called an exam anymore?
    I went through this CSA x5 - on every occasion the pass mark was being raised by 0.5 -1-2. I felt like a sacrificial lamb every time but never gave up as i had come a long way; now being part of a BME csa CONTINUAL FAILURE- statistic is so so sad. when I recently had a glimpse of this statistic had mixed emotions;

    quoted (According to the RCGP's latest annual report from 2017/18, the pass rate of the AKT exam for white doctors was 86.8% and 60.7% for all BME doctors. For the CSA exam, 93.8% of white graduates passed, compared with 83.4% of UK-educated BME graduates and 39% of internationally-educated BME graduates.)
    FIRSTLY reassured it wasn't my fault, i clearly had little chance- 39%,2ndly was it worth all the sacrifices I made.? AT the time of sitting this exam 6 BME internationally trained candidates I knew failed, all at different re-attempts levels training in various vts.
    All my foundation training has been in UK for the last 13 years and had no doubt it was achievable but i think i under estimated and brushed aside all these rumours of bias & subjectivity. Words cant explain the devastation, pain , despair, disappointment,daily torture during that 2 yr csa preparation on communication ie getting the 'Phrases right'.. expensive courses , financial difficulties and well being instability caused..I would never wish this csa experience on worst enemy.3-4 yr training programme all gone but positively so much knowledge and experience / community exposure gained. . eeh cant help thinking of those still in training. Lets hope this CSA format changes to give more chances to the likes of us that had sheer determination to be independent GPs but was unfortunate. I agree an exam should have standards, be real and be credible to measure knowledge &skills not to be made easier. Still focusing ahead and hope there will be something better waiting somewhere.

    Finding locum hospital jobs now is so competitive as PAs now able to clerk ,admit and manage patients at level of an SHO.. of course I cant work as a GP registrar
    best wishes to all those in training.

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  • @Harry: agree 100%. Training here is a complete joke. It's not even family medicine: it's nonsense Triage. You can fail the clinical knowledge component of CSA and as long as you are a white female and smile and nod sympathetically, you can pass!

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  • I for sure will give a crap to UK and will leave the country for good, once I pass this Crap exam.

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  • @klavio hurry up my friend, the door is closing for Aus. Canada still an option and NZ.

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  • Clinical skills (History taking/examination skills) far more crucial for a GP as there are no investigations immediately available for them to make a diagnosis and to formulate a management plan compared to secondary care doctors. Instead of testing for the latter skills, CSA tests communication skills(I AM NOT DISMISSING COM. SKILLS, IT IS VERY IMPORTANT). I have done both the CSA and the MRCP PACES. CSA is not fit for the purpose(in fact it is a nonsense exam probably a local nurse practitioner could pass it with least effort).CSA put sole emphasis on communication skills ignoring the most important aspect of being a primary care doctor. PACES is a decent fair exam which really assesses the competence of one's clinical skills. That is why no one complains about the MRCP exam and respected all around the world. WHO PAYS THE ULTIMATE PRICE FOR THESE BLUNDERS? IT IS OFCOURSE THE PATIENTS!!!

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  • Merlin @10.40.

    I love how you broad-brushed all those who entered the hallowed ground of General Practice via Summative Assessment as thickies. At the time I passed that oh so demanding examination I was told by my trainer that MRCGP denoted excellence whereas SA established competence. I entered GP training holding MRCP(UK) when the format still included the dreaded Short Cases section (which had an accepted failure rate of 70%) and quite frankly I saw absolutely no point in striving for an inferior qualification (namely MRCGP) when I had already been blessed with a diligent apprenticeship in clinical medicine with robust evaluation of my clinical skills. I accept that quite clearly I must be a thickie on some level as I had chosen GP as a career but your trite analysis needs calling out especially when the holders of MRCGP, at their very sharpest (eg GP registrars who have just passed) when asked to examine the respiratory system feel it is below them to actually percuss the chest and consequently get the findings backwards.Clinical excellence? Absolutely- depending on ones yardstick.

    Clinician @10.47.

    You Sir/Madam, are absolutely correct.MRCP is indeed a most respected qualification and not without very good reason. Primary Care needs more holders of this diploma, who have the skills to elicit the signs and the confidence to interpret them correctly which can only improve patient care.Both you and I know why this level of scrutiny will never be applied to GPs because the overwhelming majority will woefully fall short of the grade due to poor training, too much touchey-feeley cr#p and trainers who are also far far short of the quality this kind of exam demands.

    The prism that MRCP bestows on the run-of-the-mill practise of most GPs also shows it to be pretty poor in doing the basics to a decent standard. Ultimately MRCP simply ensures that the basics are done very well, and imparts lasting good habits which endure.And sadly, in my opinion, many GPs at some level feel threatened when their work gets scrutinised closely- they forget that such scrutiny cannot help but fall upon their work when one is doing ones job properly ie considering past events, correspondence, clinical findings and test results to accurately evaluate what is before them in any particular clinical encounter.

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  • I agree that an improvement in clinical skills, recognition of pathology etc needs incorporated into the RCGP portfolio in a more rigorous manner than the completely arbitrary and useless "CEPS" system which fixates on intimate examination at the cost of a solid CVS/Resp/Neuro/Gastro/MSK assessment - but why do we have to have such a binary approach to everything - it's possible to pride oneself on having both well developed set of clinical skills and communication skills - we shouldn't write off communication skills as "soft skills" as they can be just as tricky to navigate, and I would suggest I see more repeat visits because of poor rapport/explanation/clarity of management plans than missed pathology (though I've seen several missed symptomatic cholesteatomas recently - more so I think because I've got better kit than others rather than better skills) - though that's just my anecdotal impression.

    I would suggest more of my meaningful and useful 'pearls' picked up along the way are to do with clinical examination and spot diagnosis rather than new guidelines and management.

    I do also worry that in having a set of assessments that means you almost never have to touch a patient, some newer GPs aren't examining people with the rigor and discipline that they should primarily because of squeamishness about human contact rather than time (though this is what is always blamed as we're very good at convincing ourselves we don't have enough time for something).

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  • Introducing a MRCP-level of rigour into General Practice would be very beneficial for GPs and patients alike but two major problems with this:

    1. The sheer amount of time taken to perform a thorough examination would demand an extension of the 10 minute consultation.

    2. MRCP only pertains to medicine!! How would this qualification assess a GP's competence in dealing with cases based on O&G, gynaecology, paediatrics, mental health, orthopaedics, general surgery, ENT, ophthalmology, etc, etc? Put a vaunted medical consultant in a room with a child, a pregnant woman, a woman with period problems, a bipolar patient, a patient with an ambiguous skin lesion etc, etc and see them squirm.

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  • Klavio | Doctor in Training24 Jul 2019 6:06pm

    I for sure will give a crap to UK and will leave the country for good, once I pass this Crap exam.

    Care to clarify this comment about your intention to 'give a crap to UK'? It sounds incredibly disrespectful and hostile.

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  • Moniker @6.34pm.

    You have utterly missed the point.The issue is one of assessing clinical skills to some degree, which means for primary care hands-on detection of clinical signs.Your use of the term "vaunted medical consultant" is quite telling and misunderstands what MRCP is all about. Doing the basics well, fluidity of thinking, competent and purposeful examination (which largely comes from the experience one needs to pass the exam rather than the paper its written on) with a full recognition of how invaluable the examination is to work out whats going on, or where to go next. Experience of the other disciplines you mention are vital too and their clinical examinations techniques should also be assessed with hard signs present.

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  • Well said "sung"!!! This reminds me of an old saying "this is like blowing conch in deaf man's ears".

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  • So sad that colleagues who would be perfectly good GPs are being stopped because of an exam of dubious validity, whilst across the country GP gaps are being filled by any allied health professional who is willing to give it a go. However good these alternative practitioners are, I can't believe they are better than these so-called 'failed GPs' with years of medical training and experience. It would be more consistent to allow qualified doctors to enter GP after Foundation years, so they can muck straight in where there are GP shortages and learn on the job like the alternative practitioners can. And don't get me started on the ridiculous Performers List regulations that require UK qualified GPs with MRCGP and UK experience as partners to retrain when they have been working as GPs outside the UK for more than 2 years. No wonder there is a workforce crisis.
    Crazy thought - has anybody asked the patients what they think? I know who I'd rather have looking after me.

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  • "Care to clarify this comment about your intention to 'give a crap to UK'? It sounds incredibly disrespectful and hostile."

    I think he's trying to say that he could give a crap about the UK.

    Please feel free to report him to an official anti-patriotic agency but of course you'll also have to report anyone else leaving the UK, as they sure as hell could also give a crap about the UK.

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  • I've seen doctors who easily pass CSA, yet when it comes to daily GP work, their practice is questionable. Apparently it doesn't matter you're safe or not as long as you pass the CSA.

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  • Dear IDGAF

    Apologies-no offence intended. Feeble attempt at humour. Just trying to paint a picture of how we have got to where we currently are.

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  • Merlin @8.33.

    Relax- sincerely, no apologies necessary. I hope the other SA thickies are also this charitable(!!!). Smiley Face inserted here..

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  • The CSA is internatonally recognised as a very high quality exam. Statements like it assessing "complex statistical questions" reveal unfathomable ignorance. "complex statistical questions" are addressed in the AKT which of course nobody ever wants to talk about.

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  • @ policenthieves | GP Partner/Principal29 Jul 2019 11:00am

    The demographic difference in CSA pass-rare is hardly one of the unfathomable "complex statistical questions"?
    Quod volimus credimus libenter?

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  • I saw far too many grown, capable and intelligent men and women cry over their inability to pass this crap CSA exam to know that it had nothing to do with their clinical abilities but rather it was a deliberate and savage attempt by the establishment to bludgeon people from other ethnic backgrounds into submission. A kind of neo-imperialist mentality of “we are stronger and better than you and we will show you so”.

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  • Actually the "demographic" differences are very hard to fathom and are subject to much ongoing research if any of the commentators with there pre-set blinkered views could be bothered to look. There are a whole herd of elephants in this room.

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  • Quod volimus credimus libenter. Couldn't have put it better myself!

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  • I’m with Harry, as I have also known highly trained excellent doctors destroyed (and disappear) by this Tesco check-out training. Maybe the major demographic difference is that they perceive themselves as highly motivated and highly trained professionals and not as relatively unskilled supermarket workers?

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  • Actually the overall failure rate after four (sometimes five) attempts is vanishingly small.

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  • One would have to have 'vanishingly small' professional self esteem and very deep pockets to pursue an MRCGP, four to five times.
    When I need a doctor, I hope to be attended-on by a competent, polite professional and not somebody who wishes me 'have a nice day' with a Pan-Am smile (the superfluous is just that).
    I'm not alone in my simplistic requirements.
    p.s. 'Pan Am smile' is the only thing that remains of that company - might be extrapolated to GP UK???

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