This site is intended for health professionals only

The CSA is failing international trainees

If you are an international medical graduate, your chances of failing the clinical skills assessment (CSA) are about 50%, compared with 10% for UK graduates.1 These startling statistics shock me every time I see them.

General practice is currently the only specialty that has an exit examination, which implies your career is over if you fail the now limited number of attempts for the CSA. This has led to discontent among international graduates as well as the training community in general. Such high failure rates for a particular subgroup raise questions about the exam's validity and fairness. This has brought the role of the RCGP under scrutiny.

Raising its bar for examination standards when it clearly expected more international candidates to fail – as Pulse revealed last year – hardly gives the impression of a fair organisation. Even though it did issue an advisory paper on the CSA, it remains guilty of introducing an exit examination without appropriate support for the subgroup it knew was likely to struggle.

This rings alarm bells about revalidation too, in line with the concerns expressed by the BMA.2 The test is not just meant to examine communication but clinical skills,  and yet all the explanation being given is about communication. Anecdotal evidence suggests that many candidates who fail the CSA appear to be safe and effective doctors.

But why do international graduates struggle disproportionately? The common reasons given for candidates failing the CSA include not listening, not exploring ideas, concerns and expectations, and problems with diagnosis and treatment. But that is virtually all of the consultation. It also makes me wonder how they passed the PLAB exam and GP recruitment. Or did the system let them in to fill posts?

Also, consultation skills are learned skills. We expect a qualified GP to be able to adapt their consultation style and yet we do not adapt our teaching style for trainees with different cultural backgrounds lacking in so-called ‘linguistic capital'.

Biases and prejudices

We all know that despite the UK being one of the world's more tolerant societies, there remain biases and prejudices that increase the pressures on overseas graduates.

There is a plethora of evidence that suggests ethnic minority students fare less well in entry to UK medical schools, in final examinations, in job applications, in disciplinary action before the GMC and in the granting of merit awards.3 The reasons for such differences are far from clear. We need more research as to why international graduates, who constitute about one-third of the workforce, do less well. Any suggested predictive factors then also need to influence the demand-supply cycle at the recruitment stage.

Most deaneries are now actively looking at ways to tackle this problem head on. Encouraging trainees to have mixed study groups to foster more social integration is laudable – integration works both ways. But being an international graduate is an immense pressure in itself.

Setting very high standards to reassure the public is all very well, but the standards that have been introduced will not make the public any safer. A poor doctor with good communication skills can still pass the examination. The relationship between the non-UK workforce and the NHS has to remain symbiotic. Otherwise, we will end up causing damage to the very patients we seek to reassure.

Dr Kamal Sidhu is a GP trainer in Peterlee, County Durham

Competing interests: Dr Sidhu is an international medical graduate


1 RCGP. MRCGP Clinical Skills Assessment (CSA) Information Paper. 2011.

2 BMA. Health committee enquiry into revalidation. 2011.

3 Woolf K, Potts M and McManus C. Ethnicity and academic performance in UK trained doctors and medical students: systematic review and meta-analysis. BMJ 2011.