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The MRCGP row has left lasting damage

The past few weeks have seen some extraordinary developments in the long-running row over the MRCGP exam.

A racism expert publishing two very differently worded versions of the same research. A threat of legal action against the BMJ. The RCGP and now the GMC forced to defend themselves in the High Court, with the prospect of a judicial review dragging on into 2014.

Suddenly, a controversy that has been simmering away all year is threatening to tear the profession apart.

Since Pulse first broke the story that international doctors were considering a legal challenge to the exam, there has been intense debate about the merits of the clinical skills assessment part of the exam.

But at the heart of the issue remain two facts. First, even after adjusting for age, gender and performance against the machine-marked applied knowledge test, black and minority ethnic international medical graduates are almost 15 times as likely to fail the CSA on their first attempt as white UK graduates.

And second - and this is the figure that really stands out - non-white UK medical graduates are 3.5 times as likely to fail as their white colleagues.

Quite why remains unclear. Those challenging the exam believe it is flawed, and Professor Aneez Esmail’s conclusion in his BMJ study - though not, explicitly at least, in his report to the GMC - was that ‘subjective bias due to racial discrimination’ may be a cause. There are other possible explanations though. The CSA is not a ‘culturally neutral’ exam and many IMGs come to it from ‘a different starting point’, as Professor Esmail himself acknowledges, stressing that the ‘preparedness of candidates, based on previous education experience’ could be a factor.

What is clear, though, is that with the benefit of hindsight, the RCGP might have handled the controversy better.
The college did initially offer international doctors some concessions, but it may now wish it had offered more, such as allowing the CSA to be filmed for use in appeals.

Instead, as legal action has progressed, the college’s position has become increasingly entrenched and, in time, it may come to regret the way it has responded to Professor Esmail’s criticism. RCGP chair Professor Clare Gerada had every right to express bemusement at the apparent contradictions in the wording of his two reports. But for the college to publicly attack one of the UK’s leading experts on racism in the NHS looks bad; to threaten legal action to try to force changes to the wording of his research paper worse still.

How the case will play in court remains to be seen, but in the court of public opinion the battle may already be lost. Our survey suggests a majority of Pulse readers feel the college has handled the affair poorly - even though only a minority believe the exam itself is discriminatory.

All of which presents incoming RCGP chair Dr Maureen Baker with a real headache as she takes the reins at the college this month.

Her instinct may be to let the affair play out in the courts. But regardless of how the judicial review goes, she also must acknowledge the blow to the MRCGP’s credibility, and the damage the controversy has caused to the college’s reputation. It will not be easily undone.

Readers' comments (25)

  • An exam which has a DEFAULT PASS RATE of 98% based on gender and colour can't be an exam to ensure public safety.
    Patient groups need to investigate the matter independently.

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  • well if you think the MRCGP exam might be bias against foreign doctors , wait till there is a legal challenge to the new requirement for overseas graduate who are GP's in their own country to get on the performers list , it will make the MRCGP exam look like a walk in the park
    the reason why I know is that recently we wanted to recruit a German doctor to come and work for us and it was such a daunting experience that she finally had to leave , she was Fluent in English and a knowledgeable clinician . I'm not aware that this exam has been externally validated but happy to be proven wrong .

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  • I am completely dismayed by the RCGP's response to this matter. At no point have I heard anyone from the college try to explain/justify the 3.5x higher failure rate for non-white UK graduates - yet they state repeatedly that there is no problem with the exam! I will definitely be ending my membership of the college.

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  • I can only wish and hope that Maureen Baker has better sense than CJ.

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  • The fiasco has been a humiliating shambles for the RCGP that wants to bury its head in the sand. As a UK trained minority ethnic doctor who has British Citizenship I feel ashamed to be governed and judged by the "RCGP". I now CANNOT WAIT to pass this stupid exam and run out of this country as soon as possible, never to come back. Good luck RCGP...

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  • Where are you going....?

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  • What a disgrace for the whole medical profession this Royal College has become. I am very disappointed indeed. Staggering statistics.

    RCGP - Please, please, admit that you made a mistake in the design and conduct of the exam ( not that you are necessarily intentionally racist) and work with all stake holders.

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  • My husband is a IMG with post grad surgery + 20 years experience. He has been married to myself for 16 years. I have a Masters and I am British UK graduate. His clinical skills are beyond reproach and his English perfect yet he still fails the CSA. The RCGP need to acknowledge Prof. Esmail's findings and rectify this shambolic assessment - actors are not real patients. My Husband even overhear one of the 'actors' saying to the examiner 'sorry I made a mess of that'. Stop ruining careers, marriages and families' lives. 'RCGP HEAL THINE SELF.'

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  • What about some of the current GPs, if they go to this exam may be only 5-10%should pass , as most of them are not following any guidelines but working on the old fashion style, using beta blocker as first line for hypertension etc....But they still can work for another 15-20 years without any delay in their career/ even the new trainees who passed some of them have very superficial knowledge as they ask Clexane should BE GIVEN M? FOR e.g.

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  • IM I meant.

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  • "The college did initially offer international doctors some concessions, but it may now wish it had offered more, such as allowing the CSA to be filmed for use in appeals"

    I am going too ; see you there @828

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  • I agree with PULSE.
    CSA saga has indeed left an irreparable lasting damage to the doctors working in the UK and General public.
    I guess the college has no insight whatsoever and called this a "noise".


    Congratulations to Pulse once again for being the voice of doctors.

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  • I think RCGP dont agree for video to be recorded because there will chance of high court cases

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  • if the RCGP made me aware about possibility of failing the exam,i would not have applied.
    3 years waste of time,lots of sleepless night,high blood sugar with massive weight loss due to stress.
    is becoming GP in UK become a dream.
    dose really worth it
    advice to all my colleagues in the same boat,look after your health first.

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  • This exam has ruined lot of people's lives - including mine. Glad that it has come to a stage where some action is taken for this injustice. I am sure RCGP never thought a small minority can make a huge impact. How big the institute is does not matter, no body can bury the truth, it will come to the surface one day! I am heartbroken not to get the career I longed for and worked hard for.

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  • I find this an interesting debate, from the point of view of being an ethnic minority (educated in the UK from the age of 12) and also the son of doctor that lost a tribunal against the GMC 20 years ago for indirect racial discrimination about not being put on the Specialist Register, on a point of law (happy to expand if needed).

    I wonder if there would be such a fuss if the CSA didn't stand for a CLINICAL Skills Assessment, but a COMMUNICATION Skills Assessment?

    By way of explanation. Much of what a GP does depends on his/her ability to communicate, both verbally and non-verbally. Intuitively, this is inherently cultural. And perhaps what the CSA does (I passed first time) is examine the ability to communicate. If English is not one's first language then it follows that you may be at a disadvantage.

    To be controversial and stand up for the CSA, perhaps accusing it's test of language and communication skills of being racist, is like saying that the MRCS discriminates against blind surgeons, or surgeons with one hand, or with essential tremor.

    So I don't think the process, or the people who invented it are racist. I think it as well as examining clinical acumen it also examines linguistic and communication skills which puts candidates who's first language is not English at a disadvantage.

    The college response seems to have been to dig it's heels in, which is unfortunate. Would it not be better to say "If English is not your first language, you're going to find this harder - let's be honest."

    As for the home-grown doctors from ethnic backgrounds - that is harder to explain. I wonder if there is research about language and /or communication skills of these candidates. Are they bilingual or English-speakers? I don't know. Perhaps I am barking up the wrong tree.

    What are the alternatives? Going back to the robotic videos done with the check list of the stages of a particular consultation model sellotaped to the wall? I hope not.

    Perhaps the only alternative is to install a "fly on the wall" video camera, and consent every patient for a month (or a week or two?), video the whole lot to a hard drive and send it all to the college to assess at their leisure - that way they would really get to know how we worked - how we used the computer in the consultation, or not, how we asked for help, how we managed our time, how we dealt with emergencies and phone calls and staff. Feasible?

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  • I think the greatness of college would be to admit the mistake and try to improve the examination system or could include work place based assessment as an another options to get certification as is happening in other countries.
    please do not make it a point of ego but think about many doctors who not only are failing the exam but also failing in their life due to this mess.

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  • I am a GP trainee and is due to appear for my CSA in few months time. I don't know why is it that a doctor who has worked in UK for so many years and managed to pass other Royal College Membership exams + complete all his 4yrs of training + eportfolio stuffs + assessments + his supervisors are happy with his progress, etc. is unable to pass this CSA (Communication skills exam, sorry i meant to say Clinical skills exam) by RCGP.

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  • @Samir Dawlatly
    Ask NHS bosses not to bring in more IMGs through delegations sent to India and Asia( in case you are not aware). If I accept your argument than I am not going to waste another minute of my life in this country because I am not here to sub-serve people like you.

    I pray for future of general practice if we have GPs like you with condescending attitude to a disadvantaged group with only advice to get on with it . Would you say the same to a patient ?

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  • Una Coales

    @11:05 you may wish to read my blog article on how black and minority ethnic doctors can and have controlled bias to pass CSA.

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  • Una Coales

    @Samir Dawlatly after sitting through 2 full days of evidence and deliberation from QCs for the GMC, RCGP and affected Indian doctors in Manchester at a
    prereview hearing for a class action employment tribunal on CSA, I can confidently suggest you are indeed barking up the wrong tree.

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  • its time that RCGP seriously think about the damage they have caused to IMGs and take steps to rectify the whole exam show. Dealing with artificial patients in an artificial environment cant certainly bring realistic marks!

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  • i think GP in Uk is 15-20 % medicine and the rest is talking and listening -so having good communication skils makes some sense .
    Intrestingly entry to the training starts with an assessment of communication skills and candidates are selcted with good communication skills.What happens to those skills during training is needed to be answered by RCGP.

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  • There seems to be culture of arrogance and pompous ness in the ivory towers of RCGP. Why should we be funding such an organisation which seems to be as remote to grassroots GPs as the politicians to the public?..

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  • In my opinion the RCGP exam has always been incredibly subjective even when I did it in 1996. I failed the first time even though I was white and female. I was shocked having never failed an exam before! However, I am from a northern working class background whereas all the examiners were clearly white, male, southern and middle class. Another example of cultural bias? Needless to say having passed on the second attempt after making myself think and speak like a woolly middle class GP I decided never to be a fully paid up member as better things to spend my "brass" on!

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