According to recent RCGP statistics, as a BME UK graduate, I would be five times more likely to fail the CSA component of the MRCGP compared to my white peers. Thankfully, I took the older, four part modular MRCGP and passed with distinction.
Without the deeper analysis of these figures that is so desperately needed, it would be easy to jump on the racist bandwagon. Yet there could be a variety of reasons for the differences in communication and linguistic abilities, which is ultimately what this exam is about.
What we do not know (but could easily find out) is the social class and educational background of the CSA candidates. It is widely accepted that up to one third of medical students are privately educated. (1) It is more difficult to obtain information about the ethnic breakdown of these privately educated medical students, to ascertain a greater insight in their social class. One study does confirm the greater proportion of higher social class students among white students than minority ethnic students.(2)
It is not difficult to appreciate the huge advantages that come with a private education, particularly in areas of communication. Debating societies, presentations, drama clubs – all of these serve to inject a healthy dose of self- esteem and superiority in linguistic ability. If the majority of the privately educated trainees are white, it is not surprising that they will perform (for it is, indeed, a performance) better.
And if that’s not enough, there is also the issue of linguistic ‘capital’. This refers to the mastery of language over time, facilitated by a culture driven by family, education and other opportunities. If a UK-trained BME doctor was raised in a bilingual household, attended a state school and had very few contacts outside their own family, their linguistic capital may be reduced. Although not a linguistic example, I can recall a painful example when class and culture led to my embarrassing failure to appreciate some of the finer things in life. As a medical student, I went on a few dates with a military chef who introduced me to a tapas restaurant in Soho. As soon as I saw the look on his face, when I was chomping away at the garlic prawns, I realised I had to take the shells off before eating them. Rather than admit to being a philistine, I pretended to enjoy them better this way!
It is easy to hide behind the illusion that all GPs need to have this high level of linguistic ability in order to consult. Whilst there is no denying that good communication skills are vital for risk management and patient satisfaction, it sometimes feels that the threshold is set well above this minimum level.
As well as this, there are many inner city practices where consulting takes on a whole different form. It is not unusual for me to complete a whole surgery with patients who do not speak English as their first language. Some of these consultations will be carried out in Punjabi (I am bi-lingual), some will be carried out via an interpreter and some will be carried out in very basic English. Occasionally, I will need to access my toolbox of consulting skills, but this is mainly for the purposes of teaching and training. UK society is changing and it is a shame that the RCGP does not adequately reflect this.
Racism and discrimination are strong accusations levelled at the college and need to be backed by firm evidence. However, I can empathise with IMG trainees who believe they are being set up to fail. Many feel they have overcome all the obstacles in place – PLAB, recruitment, AKT, ARCP – only to fall at the final one.
The effects on recruitment are already apparent. There is a 15% drop in training applications as well as a drop in IMG applications. Yet the bar continues to be set higher than it was ten years ago. The NHS has always needed IMGs – without them, primary care and the NHS would have buckled. This applies as much now as it did then.
(1) GMC National Training Survey Nov 2013: Socioeconomic status questions
(2) British Dental Journal 189, 152 – 154, Aug 2000
Social background of minority ethnic applicants to Medicine and Dentistry