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Letter from RCGP on fairness of CSA exam

A letter from RCGP chair Dr Clare Gerada and Associate in Training Committee chair Dr Ben Brown on the fairness of the CSA examinations

Dear Colleague,

We are writing to set the record straight on the MRCGP examination in light of the recent claims of bias towards international medical graduates (IMGs) in the Clinical Skills Assessment (CSA).

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.

We have already met with representatives from the British Association of Physicians of Indian Origin (BAPIO) and the British International Doctors Association (BIDA) to discuss their concerns. It was a productive meeting and we hope that we are now in a constructive dialogue for moving forward.

A further meeting is being arranged for early in the New Year, to which we have also invited medical educators from COGPED and representatives from the BMA GP Trainees sub-committee.

We have both experienced the exam at first hand in recent days. I (Ben) sat a mock CSA examination in the examination centre last weekend and was reassured that the process was professional, fair and well organised. I (Clare) attended the CSA exam to observe the process. I met the actors and examiners and was extremely impressed by the high standards.

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.

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 .

Along with the two other components that make up the MRCGP qualification, the CSA has been carefully designed to ensure that new GPs are competent and safe enough to cope with the challenges of independent general practice.

All CSA examiners are experienced GPs who themselves are subjected to constant training, scrutiny and monitoring on equality and diversity. They work very hard to deliver an exam that is consistent, just and fair to all who take it.

This is an issue on which we have done a considerable amount of research. The RCGP is one of only two of the Royal Medical Colleges to routinely monitor data relating to examiner and candidate ethnicity and we have found no evidence that examiners favoured their own gender or ethnic group.

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.

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.

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.

We will continue to monitor this situation and explore the reasons why certain candidates continue to fail and work collaboratively with other organisations to see how we can offer advice to those in this position.

We are preparing a set of comprehensive FAQs that we hope will help to reassure you and we will, of course, keep you informed of developments and the outcome of future meetings.

The College greatly values its trainees and is fully aware of the pressures you face. This current situation is unpleasant and upsetting for all parties but we will see it through.

Thank you for all your support

Dr Ben Brown, Chair, RCGP Associates in Training Committee

DrClare Gerada, Chair, RCGP Council

Readers' comments (20)

  • 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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  • Agree completly with Shaba.
    All those who have been thrown out of training would end up in other hospital specialties and would have no faith left in primary care.
    It seems despite such an uproar, the college is still defendng this exam rather than trying to make it fair and transparent.
    I can bet that if this case ends in court, the college would have no legs to stand on. The reason I'm saying this is because the retrospective changes to any exam have been successfully challenged many times in the past.

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  • Retrospective changes are ILLEGAL. Fact.

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  • RCGP has no option other than to say that the exam is fair. Are you guys crazy? You think they will admit their exam is unfair?

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  • If one thousand GP trainees write to the college and protest against the discrimination and as a symbol refused to sit the next diet ... This is what college will suffer:

    1000 X 1500 = 15,00,000 pounds (1.5 Million pounds)

    Donate a quarter of that money to BAPIO who is fighting on your behalf in the court.

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  • Plans for a protest outside RCGP head office in London in January holding posters :

    BBC and Telegraph seem interested to cover the story.

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  • The whole point of this debate is: Is the exam letting the "Good" doctors through to go out in the community and practice safely and competently?

    Both RCGP and BAPIO would agree on this.

    Right. Lets move on.
    Who is on the receiving side? Not BAPIO. Not RCGP. Not Actors.
    The PATIENTS.
    Have two streams as "pilot".
    Allow the doctors who RCGP thinks do not meet the criteria to "pass", practice as a GP without the MRCGP title. (It used to be the case some years back anyways when the exam wasn't a prerequisite to become a GP anyways.
    Audit/monitor/study/evaluate/revalidate (or whatever you name it) these doctors. Look at the complains rate. Patient satisfaction in REAL world. Number of errors. Etc etc. let the CONSUMER , which is the PATIENT, decide.

    IF - this cohort is no worse in clinical practice with real patients in the real life scenarios after an year as compared to those who the RCGP pass, scrap this exam altogether.

    Does that make sense?

    We set all these standards of care etc etc to ensure doctors are FIT to practice isn't it? Let patients and GMC decide who is fit and who isn't.

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  • 1/3rd of London is ethnic minority.

    How does RCGP ensures the "communication skills" of "white English speaking" GPs is up to the mark to connect effectively with the BME community in the capital city of England?

    What if some Asian families complaint my "white" GP can not understand my ideas, concerns and expectations?

    Any suggestions RCGP?

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  • Why is the RCGP panicking?
    I would have been surprised if Ben and Clare said anything different! How could an actor 'misbehave' when the chair of the rcgp and the chair of the ait committee are doing a 'mock exam'? Is that scientific enough? The statistics show the real exam!
    I wrote to de college about 7/12 ago regarding the exam and to date not even a letter to acknowledge receipt has been sent!
    I made a complaint about an examiner and to date not had a response! What kind of leadership do we have?
    By contrast I have suddenly had 2 letters from the college this week since they had the threat from BAPIO.

    If this is a cultural and communication issue- how does the college manage to suddenly know the culture of the people of Qatar, Malta, Brunei. Etc well enough to exam them? And we're told after at least 5 yrs of working in UK we've still not learnt!

    I remember the time when all the practice staff could not believe how quickly my appointments get filled up and almost every patient I saw wanted to come back to see me! I guess this is all due to my bad communication skills!

    I finally passed my exam but I think the exam lacks specificity and sensitivity. There is something fundamentally wrong with this exam and the earlier the college comes to terms with it the better. I am saddened by what is going on as it seems to be splitting doctors into 2 groups. I think this is politically good - we can't negotiate for anything with a divided front. That's how come GPs get paid £200,000 in Australia and we struggle to make even half of that and pay higher taxes and live in a harsh economic climate. Time to reconsider moving somewhere else?

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