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The RCGP must answer CSA concerns

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.