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Independents' Day

The RCGP must answer CSA concerns

Much lower pass rates among those from ethnic minorities demand urgent investigation, writes Dr Shaba Nabi

At my university reunion at St George’s Hospital Medical School, people revelled in the fact that we had been considered the ‘cool kids on the block’ because we had been such an economically and ethnically diverse group of students.

In fact, the truth does not justify such nostalgia. In 1986, my year of entry to medical school, Drs Collier and Burke uncovered a scandal.¹ They exposed a computer programme that automatically discriminated against potential medical students who were either female or had a non-English-sounding name. I had no idea that the year I was selected, I was jumping through even bigger hoops than I had thought.

Heads rolled and reports were written, resulting in an even larger number of students from ethnic minorities in subsequent years. This did not, however, mean they were on a level playing field. In 1993, Dr Aneez Esmail from St George’s Hospital published a study with Dr Sam Everington which showed that doctors with a non-English-sounding name had 50% less chance of being shortlisted for a job interview compared to their white counterparts.² I felt I could relate to this study at different points of my life – but never more than when I applied for GP partnership posts, where having a face that fits is crucial.

More recently, RCGP statistics show that in 2010–11, the most recent year for which figures are available, the failure rate for the Clinical Skills Assessment was 63.2% among international medical graduates compared with 9.4% for UK graduates.³ It would be easy to attribute this to language and culture, were it not for the fact that a significant difference was also seen among different racial groups within the UK. The failure rate for UK white graduates on their first attempt at the CSA was 3.9%, but 15.3% for south Asian UK graduates and 33.3% for black UK graduates.

So what is the explanation for these significant differences in pass rates for the CSA exam? Is it lack of cultural awareness, lack of linguistic abilities and lack of an emotional connection with patients? Or is it something more akin to what was happening at school, when I was never given the part of Snow White despite being the best reader in the class? The truth is that we will never know without a detailed investigation into this issue – we cannot do nothing.

Reports show we are heading towards a recruitment and retention crisis within general practice over the next five years. The MRCGP, which focuses heavily on reflective learning and interpersonal skills, appears to favour white females, many of whom are likely to work part time at some stage of their careers. This is compounded further by an average 56% female intake into medical schools and a similar intake into GP training schemes. But no one seems to want to confront the ‘white’ elephant in the room.4

A multicultural society

General practice needs international medical graduates for many reasons. We live in a multicultural society where many communities do not speak English as a first language, and important chunks of an interpreted consultation can be lost in translation unless the interpreter is of the highest calibre. Speaking from personal experience, these communities benefit enormously from being able to consult with a doctor in their mother tongue and international medical graduates are in a unique position to be able to do this. From a workforce point of view, they are crucial to maintaining numbers because so many GPs are taking early retirement in view of pension changes, commissioning and revalidation.

The onus is on our college to identify and investigate the problem, while reflecting on alternative forms of assessment and evaluation. These could include videoed surgeries, joint surgeries with examiners or joint surgeries with trainers under exam conditions.

No matter which method is used, one thing is certain. It must be transparent to avoid any of the accusations of bias that are plaguing the current CSA.

Dr Shaba Nabi is a GP trainer in Bristol


1 Collier J and Burke A. Racial and sexual discrimination in the selection of students for London medical schools. Med Educ 1986, 20: 86-90

2 Esmail A and Everington S. Racial discrimination against doctors from ethnic minorities. BMJ 1993, 306 (6879): 691–2

3 RCGP (2011). MRCGP Statistics 2010-11.

4 ‘White males now classed as a “minority group” at university’. The Daily Telegraph, 19 August 2012.

Readers' comments (57)

  • Thanks Dr Nabi for raising this issue which seems to be a hot topic amongst everybody linked with general practice except RCGP.
    Hope someone amongst the elite examiners can take this issue with the RCGP board or offer their resignation citing this obvious disparity. Exams are a medium to test candidates for their knowledge and ability and not to throw about 30% of them out of training citing language reasons.

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  • Well done.
    Let's see if the College would take this seriously.

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  • Courageous!!!Dr.Nabi
    “To believe in something, and not to live it, is dishonest.”
    ― Mahatma Gandhi
    Thank you for the article Dr.Nabi.

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  • On top of this , the marks you get doesn't reflect how well you have performed. Me and my friend took exam on the same day and failed with same scores but one had too many crosses on the feedback sheet. When asked examiners from RCGP, reply was crosses doesn't reflect score. So hiding everything as no one can benefit except white females who have not finished the cases but still passed.

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  • The gross disparity in pass rate between international and UK graduates is very suspicious. The difference between white UK graduates and Asian & Black UK graduates (all of whom have passed University exams) is evidence that the CSA is racist unless the RCGP can prove otherwise. The CSA should be suspended until the RCGP can explain the disparity.

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  • Figures tell the story itself. It has been a traumatic experience going through CSA.

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  • CSA exam needs reviewing. It is clear that this form of assessment is not fair to a particular group of trainees.Why is RCGP not saying anything. Legal action is the way forward.

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  • Unfortunately few trainers are now defending RCGP's activities, my trainer would not do my report until the CSA result publishes in four days time. I know if I pass I will get a good report, if I do not pass I will get a bad one. I should get my report based on my skills while I am placed tthere, not based on CSA result, basically they are trying to put nails on your coffin.

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  • I agree with Dr.Chaudhri.
    Both the statistics and the lack of transparency of the assessment process provide a reasonable ground for such investigation.

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  • Excellent article. We need an investigation not only into the collage but also DH and NSCB in the way the exclude BME from senior posts.

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