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Trainers’ letter to RCGP

We note with optimism that the issue of discrepancy in failure rates between overseas graduates and local graduates in the nMRCGP examination has been published in ‘Pulse’. It seems evident that many GP trainees are unable to surpass the examination hurdle, or in the case of some, are at risk of succumbing to the CSA/AKT at their fourth and final attempt. It is of concern that the significant difference in the success rates of this examination appears to be based on ethnicity, and it has to be acknowledged that this puts pressure not just on the candidates but also on their families. 

The fact that General Practice is the only speciality where failing the exit examination means the trainees have no choice but to quit General Practice sets the RCGP apart from other Medical Colleges and Faculties. It should be noted that International Medical Graduates (IMG’s) have historically always formed a significant proportion of the GP workforce in the UK. A disparity in pass rate of this magnitude neither existed in old MRCGP nor is it heard of in any other comparable examination internationally. There has been anecdotal evidence that trainees deemed competent by their trainers, considered to be the best predictors of trainees least likely to struggle, are ending up failing the examinations multiple times.

This is a disservice not only to the trainees and their families but also to our patients, the general public and the taxpayer at large. We must not discount the adverse impact of GP workforce shortage on patient care in many parts of the country which have recruitment and retention problems, often filled by IMGs.

It is disappointing that the widely respected RCGP chair Dr Clare Gerada has termed the controversy as noise, we are extremely hopeful that she will not hesitate to do the needful. Though RCGP deserves credit for being transparent in publishing examination data based on ethnicity and country of graduation and has published a list of frequently asked questions to allay some of the concerns, however, this does not go far enough to identify the flaws in the process or to take appropriate corrective steps. It is time for all of us to recognise this as a real problem, even a crisis. All the stakeholders need to sit down to do a root cause analysis, debate the reasons and the potential solutions- whether this involves revamping the examinations, regionalising them, changing the way feedback is given to the candidates, video recording the examination, alternative route to qualification, extra trainee/ trainer support, additional training (and attempts) for candidates likely to fail or reviewing the GP training selection process.

Some have argued that there is a disparity in the AKT pass rates too which is a ‘computer-based test’. The AKT questions are long and unless English is your first language, this can be a disadvantage and it appears that often IMGs find it hard to ‘effectively’ finish this examination on time.

If it is the case that IMG’s perform poorly and that the examinations are accurate and unbiased, it raises the question as to why RCGP and Deaneries are allowing patients to be exposed to practising doctors who they statistically expect to fail these exit examinations. The selection and recruitment process into GP training, therefore, must be reviewed, as it is this very system that deems them competent to be trained and then during the course of their latter years of training concludes that they are unfit to be a GP. We hope that the Deaneries will work with the college to revisit this, looking beyond the short term aim of filling the training posts. Good career advice at the beginning of their careers would weed out those who are not suitable to GP training, or at least reduce the chances of such abject failures. 

It was reported in the media after a meeting of (British Association of Physicians of Indian Origin) BAPIO with RCGP that number of attempts for AKT and CSA may be increased to six Though this will help to reduce the pressure on candidates, it is patently obvious that long term solutions are required as the RCGP’s own statistics show that increasing the number of attempts does not result in significant improvement in pass rates. The impact of cost of such examinations (CSA costs more than £1500 per attempt) can not be understated at that stage of a trainee’s career.

RCGP, as a body that conducts the examination and has a monopoly position on this has a moral obligation to acknowledge and address any concerns raised irrespective of the source and reasons. It must respond to the concerns raised by the trainees, organisations such as BAPIO, trainers, GPs, doctors or the taxpayer. Otherwise, it risks alienating itself from the profession.

We take this opportunity to kindly request the college to review the nMRCGP examinations i.e. AKT and CSA with urgency.

Signed by

Dr. Aninda Banerjea

Dr. Keith Birrell                    

Dr. Anne Blandford

Dr. Neil Brownlee

Dr. Richard Croft

Dr. Raj Dussad

Dr. Eamonn Kennan

Dr. Nageswarao Kolla

Dr .Nasir Nabi

Dr. Uma Narayanan

Dr. Vidya Parajulie

Dr. Geoffrey Potter

Dr. Selvarajan Rajarajan

Dr. Anand Rischie

Dr. Nitish Sahoo

Dr. Sangeeta Shah

Dr. Kamal Sidhu

Dr. Manjit Suchdev

All signatories are GP trainers except Dr Potter who is a former trainer