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A faulty production line

RCGP study finds CSA exam is fair

Exclusive: The RCGP has revealed that a major study into the CSA exams  found ‘no substantial effects of gender or ethnicity on examiner/candidate interactions’ in an effort to ‘set the record straight’ on accusations that the exam was biased against international medical graduates.  

Dr Ben Brown, chair of the Associates in Training Committee and RCGP chair Dr Clare Gerada sent a letter to all associates in training today (Friday 21 December). It said that a review of 52,000 cases, carried it out in conjunction with King’s College, had shown the exam was fair and that there were ‘no substantial effects of gender or ethnicity on examiner/candidate interactions’.

The RCGP said the full results of the survey would be released in the new year. It also said the RCGP will undertake a survey of candidates’ views of the exam in February.

Figures from 2010/11 show that the failure rate for international graduates taking the CSA component of the MRCGP was 63.2%, compared with 9.4% of UK graduates.

The British Association of Physicians of Indian Origin has said it is considering a possible judicial review if talks with the RCGP do not provide a resolution.

Dr Brown and Dr Gerada wrote: ‘This is a sensitive issue but please be assured that we are treating this accusation very seriously and that a lot of work is going on behind the scenes.’

‘The RCGP sets the standards for general practice in the United Kingdom. In order to consistently improve patient care, it is essential that our assessments are as valid, reliable, quality assured and rigorous as possible.’

Both doctors sat mock CSAs in recent days, the letter said, and they were ‘extremely impressed by the high standards’ of the examiners and actors and were ‘reassured that the process was professional, fair and well organised’, they said.

They wrote: ‘The CSA is a reliable exam that reflects the diversity of general practice and the diversity of our patient populations. It is designed to test the complex tasks that make up a GP consultation, namely the ability to apply and integrate your clinical, professional, communication and practical skills to the general practice setting and communicate clearly and effectively with all patients whatever their situation.’


The RCGP is one of only two royal colleges that routinely monitors candidate and examiner ethnicity, they said.

They added: ‘Researchers have recently reviewed 52,000 cases and found no substantial effects of gender or ethnicity on examiner/candidate interactions. In addition, the Applied Knowledge Test (AKT), which is anonymised and marked electronically, shows similar patterns to the CSA. Of the International Medical Graduates who pass the CSA first time, 40% score highly.’

‘We appreciate that as trainees you have already been through years of medical education and that the exam process can provoke some anxiety. But , as in any exam, a pass cannot be guaranteed just because you have completed your training and paid to take the exam.This would be a great disservice to you, the College and, most importantly, to patients.’

The letter added: ‘On the subject of fairness, the RCGP undertook an exit survey of candidates before they knew their results in February 2011. In answer to the direct question “Is the CSA fair?” 92% answered yes. Of the failed candidates, about twice as many thought it was unfair as the passing candidates. We will be doing another candidate survey in February 2013.’

Readers' comments (306)

  • The defensive attitude of the College really saddens me. I have been very fortunate and have done various roles in the NHS and met lot of wonderful people from all walks of life. Many have helped and supported me when I spoke about discrimination and differential treatment of BME/IMG doctors, be it in relation to clinical excellence awards, disciplinary action, GMC decisions or exam results. I owe lot of gratitude to many wonderful people.
    But what really saddens me is the College attitude towards CSA exam results. RCGP leaders are behaving like a doctor who has no insight! Unless the College accepts that there may be an issue the College will not change.
    No exam can be fair where UK trained BME doctors chance of failure is 6 times more likely compared to UK trained ‘White’ trainees and for IMGs failure rate is 20 times more! Such an exam can never be fair. This exit exam has ruined many good IMG doctors’ lives and College has to take some responsibility for this. Neither BAPIO nor BIDA wants to see ‘bad doctors or doctors who are unfit to be GPs to be GPs irrespective of ethnicity or country of origin. I am not aware of any study which shows that doctors who pass the exit exam make better doctors than those who have failed. Such a high failure rate creates artificial shortage of GPs and this would suit many College members. Time is right for GMC to take over the exam or to remove the exit exam all together or to come with a fair exam which benefits patients, NHS and the Country and not the College or College members.

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  • Any report on examiner bias. Video the examinations and review the conduct of examiners and role players. We are talking about some role players and behaviour of some examiners. How do you get that straight. This report does not answer the burning question. Img have no problem with the cases. The problem is examiner/role player bias . How do you elimate this or make sure it does not happen? Only video evidence. Who actually suggested this biased research. The amswer to such a research will always be positive. Please wake up and do something constructive about this exam rather than easting money on meaningless good for nothing research.

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  • What is seriously wrong here is that the college conducted its own study. Despite all these accusations just see how defensive the college is. I am now beginning to believe what Imgs are saying about the college.

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  • Interesting. I agree with Dr Prabhu that this is really sad. Instead of demonstrating empathy, fairness and transparency, college has come up with some statistics to show "all is well".

    I have been following these discussions with great interest. I agree with the above responder that people are beginning to believe the "noise" wasn't merely a vent from the IMGs.

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  • If it's a fair exam/system, it needs to get its priorities right. If a doctor managed to enter on to the VTS scheme and had no problems with all other assessments including AKT but fails on CSA repeatedly, then the system should assess the trainee 'holistically' first before throwing them out!
    Is it fair the trainee is thrown out with nothing for failing by a few marks? Also the trainee has no idea why they keep failing as the feedback is not constructive and not even the trainers know what to do.
    The trainees life is then then shambles, without knowing what to do, called by a failure by the systems..
    Should the final exit exam be a communications exam or a clinical exam? What is the ultimate role of a doctor?

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  • Just look at the statistics!!!!!!!!!!!!!!!

    How can you call this FAIR?

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  • Dear Clare,

    "If racist consequences accrue to institutional laws, customs or practices, that institution is racist whether or not the individuals maintaning those practices have racial intentions."
    The Commission for Racial Equality

    I think a point is being missed here. It's not just the processes that need to be scrutinised; but the CSA exam itself.

    And while I'm on the subject, the entire nMRCGP needs to be reviewed. We are producing a generation of anxious, stressed and overworked GPRs when it should be the most enjoyable year of their career. The entire bar is set too high and the consequences of this will be only too painful in years to come when we are faced with a massive recruitment crisis. Those of us who are in the inner cities are already experiencing it.

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  • Don't see any point in these discussions. An INDEPENDENT assessment is needed - a judicial review is needed.

    Then the fairness can be judged.

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  • Look at the US primary care pass rate of IMGs
    In the US <10% difference between the Local and IMGs.
    United States 86.7%
    Canada 83.9%%
    Other International 77.2%
    If IMG are failing whose fault is? Trainee /Trainer / deanery/ RCGP.
    1. Is it only RCGP do this kind of study.
    2. Can RCGP explain why the US is passing 77.2% IMGs

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  • "@clarercgp: MRCGP (CSA and AKT) FAQs @RCGP Please RT"

    Good FAQs but not clear about cameras missing cues in a videoed consultation. A very good reason not to video.

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