A racism expert publishing two very differently worded versions of the same research. A threat of legal action against the BMJ. The RCGP and now the GMC forced to defend themselves in the High Court, with the prospect of a judicial review dragging on into 2014.
Suddenly, a controversy that has been simmering away all year is threatening to tear the profession apart.
Since Pulse first broke the story that international doctors were considering a legal challenge to the exam, there has been intense debate about the merits of the clinical skills assessment part of the exam.
But at the heart of the issue remain two facts. First, even after adjusting for age, gender and performance against the machine-marked applied knowledge test, black and minority ethnic international medical graduates are almost 15 times as likely to fail the CSA on their first attempt as white UK graduates.
And second – and this is the figure that really stands out – non-white UK medical graduates are 3.5 times as likely to fail as their white colleagues.
Quite why remains unclear. Those challenging the exam believe it is flawed, and Professor Aneez Esmail’s conclusion in his BMJ study – though not, explicitly at least, in his report to the GMC – was that ‘subjective bias due to racial discrimination’ may be a cause. There are other possible explanations though. The CSA is not a ‘culturally neutral’ exam and many IMGs come to it from ‘a different starting point’, as Professor Esmail himself acknowledges, stressing that the ‘preparedness of candidates, based on previous education experience’ could be a factor.
What is clear, though, is that with the benefit of hindsight, the RCGP might have handled the controversy better.
The college did initially offer international doctors some concessions, but it may now wish it had offered more, such as allowing the CSA to be filmed for use in appeals.
Instead, as legal action has progressed, the college’s position has become increasingly entrenched and, in time, it may come to regret the way it has responded to Professor Esmail’s criticism. RCGP chair Professor Clare Gerada had every right to express bemusement at the apparent contradictions in the wording of his two reports. But for the college to publicly attack one of the UK’s leading experts on racism in the NHS looks bad; to threaten legal action to try to force changes to the wording of his research paper worse still.
How the case will play in court remains to be seen, but in the court of public opinion the battle may already be lost. Our survey suggests a majority of Pulse readers feel the college has handled the affair poorly – even though only a minority believe the exam itself is discriminatory.
All of which presents incoming RCGP chair Dr Maureen Baker with a real headache as she takes the reins at the college this month.
Her instinct may be to let the affair play out in the courts. But regardless of how the judicial review goes, she also must acknowledge the blow to the MRCGP’s credibility, and the damage the controversy has caused to the college’s reputation. It will not be easily undone.