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GPs go forth

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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