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Academic performance of ethnic minority candidates and discrimination in the MRCGP examinations between 2010 and 2012: analysis of data

BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f5662 (Published 26 September 2013) Cite this as: BMJ 2013;347:f5662

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Re: Academic performance of ethnic minority candidates and discrimination in the MRCGP examinations between 2010 and 2012: analysis of data

I work in inner city Leicester, with its diverse cultural and ethnic patient, student and medical professional groups. Many of my GP colleagues spend over 50% of their time consulting in Gujarati, Urdu, Hindi or Punjabi. I work with a large number of doctors who fail the CSA exam, many of whom are deemed to be good doctors in their work place assessments, some of whom have been offered jobs in their training practice. I have also been a GP programme director and a CSA examiner for many years, finishing these roles this year. I personally think the evidence indicates that the CSA is a reliable exam – but why are good doctors failing, particularly IMGs?

From my work with these doctors I think the reason is that IMGs and doctors who trained in the UK but who come from a BME background are disadvantaged when it comes to the CSA in different ways. The more of these areas a doctor has to deal with in the exam, the more balls they are juggling, and the harder it becomes to pass.

I have developed this list of factors through discussion with the IMGs and BME doctors I have worked with, and while I cannot ‘prove’ any of them affect CSA pass rates, or pass rates in other similar exams, intuitively they seem relevant, and in need of consideration.

1. Many IMGs have never formally been taught consultation skills until they commence GP training. UK doctors do this from year 1 at medical school.

2. Many IMGs have never trained with a role player prior to preparing for the CSA, or GP training. UK doctors usually do this from year 1 at medical school.

3. Many IMG and BME doctors spend a large part of their training time consulting in languages other than English (1). The exam is in English.

4. With a switch, for example, to an Asian language, doctors often describe a patient expectation of a more doctor-centred consultation. Appropriate patient-centeredness is seen as good practice in the UK.

5. The exam is not a real consultation, it is a simulated consultation. The doctor is required to ‘suspend disbelief’. UK trained doctors, who are often used to acting and role playing from primary school onwards, frequently appear to find this suspension of disbelief easier than their IMG colleagues.

6. Evidence indicates that role players behave differently to real patients, asking more questions and saying more words. (2)

7. The power dynamics are different. Institutional power is no longer with the doctor but with the patient and the exam. Does this have a more adverse impact on those used to the more hierarchical structures often seen in other health care systems?

8. Ethical approaches are often different in other cultures (3), for example a relational approach to autonomy is often more common in Asian cultures, than in the UK.

9. Male IMGs have a higher failure rate in the CSA than female IMGs. The MRCGP exam covers the whole curriculum, but there are a lot more ‘female problems’, which more commonly present to female doctors in GP practices, than ‘male problems’. As a result there are a larger number of problems for male doctors to learn to handle, which they are less likely to encounter in real life practice than their female colleagues.

10. Medical jargon is commonly used by IMGs – often being seen as good practice where they trained – whereas UK trained graduates have been taught to avoid jargon from year 1 at medical school. Some IMGs need to learn to avoid jargon.

If many or all of these are true, in the environment of an expensive high stakes exam, male IMGs have more balls to juggle than any other group, female IMGs coming next. BME doctors who trained in the UK, who consult in other languages, have more areas to contend with than their white UK trained counterparts. White women training in the UK generally have the least number of balls to juggle. Is it therefore a surprise we have the pass rates we do?

The questions is: ‘What are we going to do about it and what are we going to do for those doctors who have been unable to pass the CSA but are deemed by their trainers to be good doctors?’ This is a question for our whole profession: GMC, deaneries and RCGP alike.

1. Diversity: what is behind the CSA failure rates? Knight, Chris; Knight, Rhona – Education for Primary Care, 2009 Education for Primary Care, Volume 20, Number 5, September 2009 , pp. 397-401(5)
2. The simulation game: an analysis of interactions between students and simulated patients.
De la Croix, Anne; Skelton, John – Medical Education, 2013 Volume 47, Issue 1 pages 49-58
3. The experience of working within a different professional framework. Report for the General Medical Council, February 2009, Executive Summary http://www.gmc-uk.org/Executive_Summary_2_09_AS.pdf_25402925.pdf

Competing interests: MRCGP examiner 2001- 2013; Training programme director 2005-2013; Author of Essential nMRCGP CSA Preparation and Practice Cases; FRCGP

01 October 2013
Rhona A Knight
Portfolio GP
Personal view
Oakham, Rutland LE15