Since the introduction of the new-format MRCGP exam nearly a decade ago, the controversies around it refuse to die down. A format that was meant to improve standards and quality in primary care has become a source of immense stress for trainees and trainers alike.
The clinical skills assessment (CSA) arm is prohibitively expensive to undertake and dreaded by trainees. A large amount of training time is spent on preparing for this examination, to the extent that it risks diluting the focus on training as a GP on the ground. The training schemes and authorities are having to put on extra courses to prepare trainees for it and trainees are now having to undertake expensive preparation courses.
Some who fail to pass the CSA or the AKT are needing to undergo behavioural training around examination techniques. Many have needed time off work and counselling with distress to them and their families. There are all kinds of perceptions amongst trainees, including what kind of clothes to wear on the day of the examination and which part of the year to undertake it to maximise their chances of success. The disparate failure rates and variations based on ethnicity as well as place of primary qualification are the widest ever, as reported in Pulse. An Asian male or female knows right at the outset that he or she is much more likely to fail, even if a UK graduate.
Surely this is not the outcome the RCGP wanted? And, yet, no real solutions have been proposed and the RCGP continues to defend a flawed examination.The training community too is divided on whether MRCGP is really fit for purpose.
In recent years the MRCGP has been the subject of a highly controversial review pointing to racial discrimination, followed by a legal challenge – in which the British Association of Physicians of Indian Origin won a ‘moral victory’ despite losing the case. No real progress has been made since, although former RCGP chair Professor Clare Gerada has questioned the need for the CSA.
Meanwhile we are losing hundreds of trainees who fail the MRCGP and funding the training of a large cohort of trainees undertaking the CSA repeatedly, yet the Government is launching industrial scale recruitment from abroad.
Yet another review
On this backdrop, perhaps it is no surprise the RCGP has ordered another review of the exam. But we have seen many reviews already, including the protracted legal battle.
The fundamental basis for the format has been repeatedly questioned. We do not want more funds to be spent on yet another review. We need a system that is more responsive to the current needs of the profession. Practices are closing due to recruitment failures and there are no GPs to see patients during the day as well as out of hours. The quality of the system is being diluted, and other professionals with their own but different skillsets are being parachuted in to take up GP roles specialising in people, families and their medical needs.
There has been no evidence that the new format has resulted in a better quality of GPs. There is equally no evidence that the previous format of summative assessment resulted in poorer quality GPs. So, let us not hide behind the quality argument here. I fear that harm is being done due to a shortage of GPs and there is no way in the system to measure or capture it.
The way forward
The fitness of the current format has already been debated and questioned too often. We must work on introducing a different format, one that responds to the realities of the recruitment crisis, a format that responds to the diversity of trainees and a system that is more humane. We need a format that is fair to the public and the taxpayer.
We need to place more trust in assessments by trainers who work with these trainees on a daily basis. They should be allowed to be the best judge of their communication and clinical skills. The CSA component is too focused on communication and the balance needs to be reset. The AKT component demands trainees to remember information that most GPs have easily available to reference to in the consultations – for example, DVLA guidance.
The cost of the examinations needs to be reduced urgently and alternative routes must be allowed as a choice. We also need to decide whether we want an exit examination, or whether there should be options for those who may not meet these requirements and yet can contribute effectively to the profession so as not to waste the thousands of pounds spent on their training.
We must be allowed to prepare the trainees for real general practice and how we help them cope with the demands and optimise their contribution to general practice. The College has not even agreed to the demands from BAPIO for more transparency in the examination, including videoing of the assessments and dual examiners. We are now at a stage where action must be taken and the time is now.
If we ask the same question, we will get the same answer. It is time to move on and take meaningful steps now; continuing to justify the current system is not the answer.
Dr Kamal Sidhu is a GP trainer in Blackhall, County Durham