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A faulty production line

Dr Maureen Baker: 'We agree that further action is necessary'

Statement from RCGP chair Dr Maureen Baker after the High Court’s verdict that the MRCGP exam was lawful

We welcome the verdict of the Court that the Clinical Skills Assessment (CSA), run by the RCGP, is lawful and fair.

Patients have a right to expect safe care and it is our responsibility to ensure that all doctors who qualify as GPs meet the highest standards to ensure this safe care. That is the purpose of this exam, and the other requirements to become a practising GP.

As an organisation committed to equality and diversity, we take multiple steps to ensure that our exam is robust, but fair to all candidates. These steps include giving our examiners and role players equality and diversity training, and ensuring that our examiners and role players come from diverse backgrounds.

The RCGP has been at the forefront of identifying the differences in pass rates for some time, including that international medical graduates do not do as well in the exam as those from UK medical schools.

Indeed, we were the first of the Medical Royal Colleges to publicly raise this issue and have commissioned and supported extensive research to understand what is happening and to try and identify what the causes may be.

We have always been, and remain, concerned by this issue, and are determined to continue to work with all other interested stakeholders in both understanding it, and looking to remedy it.

This will include working with both the GMC, as our regulator, and also with the training deaneries / local education and training boards who have responsibility for the training of those who take the examination. We will also continue to work with BAPIO, the British International Doctors’ Association (BIDA) and the BMA in relation to this issue.

We agree that further action is needed, and we are already working hard to find the best way of supporting the small number of trainees who fail to pass the CSA component of the MRCGP licensing exam to give them every chance of passing the exam.

We are already developing further web-based learning resources and publications to help trainees and their trainers prepare for the exam and are reviewing how to improve the quality of feedback that candidates receive from the exam so that they can target any areas of underperformance with their trainer.

We are also committed to acting on recommendations made in recent reviews to ensure the MRCGP minimises any possible risks of unfairness and we are very keen to work with the GP training community to develop effective training strategies for those who might struggle with the exam.

Overall, around 95% of candidates will pass the CSA. Of the College’s 30,271 Fellows and Members, who have declared their ethnicity, 30% are from a BME background.

We hope that today’s judgment means we can now draw a line under the events of the past year and concentrate on delivering a robust and fair exam for future generations of GPs and for the benefit of our patients.

Readers' comments (20)

  • can I ask what will happen to those who have failed 4 times and out of training?

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  • Does anyone know what are those recommendations?
    What is in place for those who are out of GP practice only and solely because of CSA?

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  • @7:42pm
    "What is in place for those who are out of GP practice only and solely because of CSA? "
    They can visit their own GP who can arrange counselling. BMA can offer career advice. It is up to the individual to decide how they wish to proceed. The exam is legal and fair.

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  • I am not an IMG, I do however believe that the BAPIO’s claim was made in good faith and I really feel for the IMGs that are affected by the CSA.

    Prior to the new borderline method used for the CSA from 2010 there were no issues regarding the CSA. Pre-2007 there was no CSA requirement to become a GP and most GPs have never sat the CSA.

    The main argument was with the new method of marking. Candidates are given scores out 3 in three domains in each station. For a bare pass on average you need to score 2 out of 3 in each of the domains. As the domains are marked 0 to 3, just to pass you need 3/4 of the marks in each domain in each station and therefore 3/4 of the marks overall. This is on average as each station has a slightly different pass mark – which I won’t bore you on (you read up on the RCGP website). I’m sure for some candidates it is difficult to score 3 out of 3 in any domain. Should you find one station difficult, you may end up scoring only 3 or 4 out of 9 for that station and it will be an almost impossible task to make up your marks.

    IMGs are mainly excellent doctors however we know and they understand that their communication is probably not as good as British doctors, especially white British doctors. They may perform really well in a station however due to subtle communication differences an examiner is probably more likely to give them a 2/3 rather than a 3/3. If they mainly score 2/3s in most domains through their exam but then stumble upon one station they can easily end up failing the exam.

    It is interesting that the mean mark for the CSA exam for each cohort of candidates is very close to, usually only slightly higher and sometimes even lower than actual pass mark. This means that if you performing about average compared to all other GP Registrars you could end up failing the exam. Your performance could well be within one standard deviation of the mean mark and you fail the exam. I don’t think it is fair if you score the mean mark or just below the mean mark that you should be failing.

    I am sure there are many practicing GPs who would not pass the CSA – they are allowed to practice as GPs and I am sure they are excellent doctors for their patients and colleagues. The GP Registrar however who may perform really well on the work based assessment, have excellent trainer and patient satisfactory questionnaire reports, passes the AKT well and then fails the CSA by one or two marks (around about the mean mark) is not allowed to practice as a GP.

    I’m sure extra support is given to failing candidates and much extra support is needed. I’m not sure however how much a difference it makes for passing the exam. The percentage of GP Registrars who fail the exam at a second sitting for both UK and non-UK graduates is greater than the percentage of GP Registrars who fail at their first sitting. This has been the case for every year from 2010. I think issues of performance anxiety set in – probably related to the high stake nature of the exam. If you do not pass you cannot practice as a GP and you have just wasted 3-4 years of your life. Although training will help some candidates, there are dozens of IMGs that are failing by 20 or so marks. I’m sure many are excellent doctors. It may just be the case that their communication skills are not up to scratch for the CSA but I don’t know what will help these candidates unless they are born again in the UK and become UK graduates and communicate as locals? I’m sure many feel it is an impossible task as some ways in which we communicate and consult are so embedded.

    There was a time when you could choose to become a GP, you didn’t have to go through the selection centre process. We now only aim to select the best candidates. For example, in the Yorkshire Deanery around 250-300 candidates are offered GP training posts from the 450+ that apply every year. Most of the jobs are offered to British medical graduates. Why are we now failing 60%+ (at first attempt) of the IMGs on their final hurdle when they make it through everything else.

    I don’t know what the answer is for the CSA to reduce the number of IMGs that are failing. I don’t think it can continue to exist in its current form. As a minimum goal posts will need to change to allow more IMGs to pass – this is not to say that the standards are reducing. Its just that the standards have been set too high for IMGs making it an impossible task for some of them to pass. Not many years ago there were no real standards, MRCGP was optional and for those who undertook it there was no CSA. No one is saying those GPs are not good enough or not safe and neither am I, so why can’t the CSA change in the way that candidates are marked.

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  • what is further action Maureen Equality and diversity e learning course to all trainers and trainees?
    Reflecting it in e portfolio

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  • Do not enter gp if you are an img or bme doctor. people have lost lots of money and livelihood because of this assessment process

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  • Dear Dr Baker ,
    As an inner city GP and advanced trainer now for five years in the West Midlands ,and having managed to get 5/6 imgs through csa , one on his fifth attempt , I do believe that all trainers need to have a much deeper understanding of the csa , now it is a licensing exam.

    Sadly the one registrar who failed twice during his time with me cited the above issues as to why he didn't pass , and didn't follow my advice.

    The others are now happily qualified gps.

    The registrars who I have trained on six month extension placements arrive very disheartened , often depressed , some having never experienced failure before in their professional career.

    The overriding message I have is that trainers need to be far more critical of their registrars consulting style during their (often now eighteen months in two practices) gp attachments.

    There is nothing more demoralising for a registrar to be told they will be fine by their trainers and then failing this very difficult and expensive exam!

    Often it is small changes to their style that are needed , not whole scale as their knowledge base is very good , most having passed AKT at the first attempt.

    Now the case is over I hope the RCGP realise what needs to be done to improve the training provided , the CSA exam is very fair but very difficult to pass , compared to the previous requirements to become a GP pre 2007.

    Let's hope we get excellent gps to drive our profession forward from all backgrounds in the future.

    Best wishes

    Savio Gaspar

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  • Will you video the exam and allow a second examiner to enhance the openess and bias? If this happens i trust Dr Maureen is really serious about fairness and robustness of the exam.Otherwise it would sound like the same old rhetoric by the RCGP for last 4 years.

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  • hey anonymous at 19.43 and 19.48.
    Thanks for the sermon. Its clear you have been one of those who have benefited from the way the exam is run at present. With regards to knowing how tough medicine is ,be in no doubt that all IMG DO know that. and when they move out they face much higher odds than what you would have ever faced or will ever face with the system being set up to favour people like you.

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