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A faulty production line

The profession must take decisive action to address concerns over any potential racial discrimination in the CSA exam

The BMA’s Dr Krishna Kasaraneni discusses the MRCGP assessment and how the profession can move forward

It goes without saying that patients and doctors need full confidence in how a doctor’s clinical skills are assessed – ultimately this can determine whether or not a trainee doctor can move on to a career as a GP. For this reason it is vital that the Clinical Skills Assessment (CSA), which makes up part of the RCGP’s membership exam, stands up to close scrutiny.  

The BMA has been aware, as have others, of mounting concerns about the disparity between CSA pass rates among UK black and minority ethnic (BME) candidates in comparison with their white colleagues. These concerns resulted in an independent review of the exam, commissioned by the GMC and carried out by Professors Aneez Esmail and Chris Roberts.

Worryingly, the review found the first-time failure rate for UK-trained BME doctors was 17% compared with just 4.5% for white UK-trained doctors. To put it another way, BME doctors trained in the UK were almost four times more likely to fail the exam at the first attempt than UK-trained white doctors. The review also found BME doctors trained abroad were 14 times more likely to fail than white UK-trained candidates.

Of even greater concern to me, as incoming chair of the BMA’s Equality and Diversity Committee, was the finding, based on six months of research, that Professors Esmail and Roberts could not ‘confidently exclude’ bias from the examiners in the way they assess non-white candidates.

But this is not a situation that is by any means restricted to the RCGP. It goes much wider than that, which is why the BMA feels that the concerns raised must be acted on as quickly as possible. As a profession we need to be clear that the situation as it stands is not acceptable and decisive action must be taken. This is why the BMA is supporting the British Association of Physicians of Indian Origin (BAPIO), which has instigated a judicial review into the disparity between the pass rates. We have contributed £20,000 plus £5,000 worth of legal advice in support of the legal challenge.

It’s simply not credible that such a difference in pass rates can be explained by clinical ability alone. Sociolinguistic factors have been suggested as a possible explanation but we do not feel these factors should play such a significant role in an assessment where the focus is on clinical skills. We have to accept that subjective bias owing to racial discrimination could be a cause of the lower pass rates.

To claim that no problem exists does not make the problem disappear. Absence of absolute proof of racial discrimination is not the same as absolute proof of absence of racial discrimination. To this end the BMA is gathering information from doctors about their experiences of the CSA, and their views on what needs to be changed. Ultimately, this work will inform the BMA’s next steps on the issue, and in the short term will go towards supporting BAPIO’s legal action.


So what else can be done? The BMA has called for video recordings of assessments to be made to support feedback and appeals, and for the number of opportunities to retake the CSA to be increased from four to six, with candidates allowed to sit it every two months. We would also strongly recommend that the actors and examiners used in the assessment are representative of the wider population
in terms of diversity.

We would like to see two examiners used at every station of the assessment, mirroring the system used by the Royal College of Physicians, which would allow for greater transparency. And we would welcome further research into what happens to those doctors who are forced to withdraw from training due to these ongoing issues and the potential impact of this on GP workforce numbers.

The review also highlighted the importance of identifying those who require additional support early in their training programme, and we would accept there is work to be done with trainees as well as assessors, which is why identifying best practice in training and assessment is essential.

Even with the above actions, more work will be needed to understand in what form subjective bias may exist in the exam system and how it can be eliminated.

It is important that we do not start to play the blame game on this issue. But it is vital that the public has confidence in the way exams are run, and BMA members should be confident that competition is fair and that if there is any risk of bias, action is being taken.

Dr Krishna Kasaraneni is the new chair of the BMA’s Equality and Diversity Committee, chair of the GP trainees subcommittee of the GPC and a GP trainee in Rotherham

Readers' comments (19)

  • Anonymous 2.38
    You too are missing the point!
    Trust are going bust due to insane PFI deals for hospital building initially supported by Gordon Brown and continued by the Tories!
    Our children's children will still be paying thes bloated mortgages!!

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  • Yes, the politicians' objective is to blame GPs for the privatization of the NHS. We should never have got involved in CCGs in the first place and it ill- becomes those who advocated them to start issuing warnings.

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  • Very well written article.

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  • Csa justice needs to be speeded up .
    This process is moving so slowly and painfully.
    CSA affected GP Trainee.

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  • Justice delayed is justice denied

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  • There should be an independent investigation into quality control of examiners.

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  • IMG GP trainees who are being released from training failed at multiple levels.
    - Selection process
    - By the deaneries/programme directors
    - By theTrainers
    - By the RCGP
    - By the GMC
    It is not fair to blame only the executioner for executing the innocent victim while judges and the jury sit is silence.

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  • "Sociolinguistic factors have been suggested as a possible explanation but we do not feel these factors should play such a significant role in an assessment where the focus is on clinical skills."
    Precisely Dr. Kasaraneni!!

    What they forget to explain,
    a. Sociolinguistic factors of the IMGs who pass the exam is no any different to the ones who fail.

    b. IMGs who pass on their 3rd, 4th,or 5th attempt miraculously suddenly fit into the socioliguistic standards within a matter of 12 -18months while they could not fit into the latter although they have been trained in this country for multiple years prior to failing the exam for the first time.

    In my opinion, This reflects only the level of callousness and the level of intelligence those who make such explanations to justify the differential pass rates. I pray to the lord ,one day they will find peace within them selves for the distress inflicted upon the hundreds of innocent doctors.

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  • Well done Dr. Kasaraneni!
    Keep up with good work. In my opinion, CSA exam has become very personal to the establishment. Either you are with us or against us. It seems that CSA lost its purpose. That might be one of the reasons some one like your self failed the CSA first time.
    Be the Mandela for the discriminated minority doctors in the country. I know you will go a long way. The guys out there who set up road blocks in your way are no where near your caliber or in your league.

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  • Well done for bringing up multiple points. Whilst I think that language can be an issue, it is definitively only in a very tiny minority. A lot of the problems lie in how trainees come across, using repetitive phrases all the time, for example, which examiners dislike. These are points which should have been addressed with the trainer. A lot of trainers however have never passed the CSA and don't have a clue and some simply cannot be asked. Knowledge is not the problem in the vast majority of cases; if anything, it is better than that of local trainees! Some trainees who have failed with one trainer stay with the same one for the second attempt and fail again. Having exams every 2 months is a little pointless as it does not give enough time to change matters. It is practically impossible for an IMG to practice the CSA with a local graduate as they cannot be bothered, are clustered in their own groups and know that they will pass anyway. The discrimination already starts at trainee level. It would also help to have the exam in multiple centres and to reduce the cost of the exam itself. Last but no least, video recordings of the CSA are a brilliant idea and should be used to feed back to the trainee- this could be general and not case bound given the fact that it is quite possible to get the same scenario twice.

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