Letters Discrimination in the MRCGP exam

Reasons why doctors who perform well as doctors may fail the MRCGP clinical skills assessment exam

BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f6438 (Published 29 October 2013) Cite this as: BMJ 2013;347:f6438
  1. Rhona A Knight, portfolio general practitioner1
  1. 1Department of Medical and Social Care Education, University of Leicester, Leicester, LE1 7LA, UK
  1. rk89{at}le.ac.uk

Many of my GP colleagues spend over half of their time consulting in Gujarati, Urdu, Hindi, and Punjabi. I work with doctors who fail the clinical skills assessment exam, many of whom are deemed to be good doctors in their work place assessments and some of whom have been offered jobs in their training practice. I think that the evidence indicates that the clinical skills assessment exam is reliable, but why are good doctors failing, particularly international medical graduates?1

This question is for our whole profession—General Medical Council, deaneries, and Royal College of General Practitioners. My suggestions include:

  • 1 Many international medical graduates have never trained with a role player or been taught consultation skills before specialist trainee year 1

  • 2 Many international medical graduates and doctors from British minority ethnic groups commonly consult during training in other languages.2 The exam is in English. Switching to an Asian language is, anecdotally, often accompanied by patient expectations of more doctor centred consultations

  • 3 The exam is not “real,” but simulated. The doctor must “suspend disbelief.” UK trained doctors seem to find this easier than international medical graduates

  • 4 Role players behave differently from real patients, asking more questions, saying more3

  • 5 Women with “female problems” more commonly present to female GPs in real life practice. Male candidates are therefore less accustomed to managing such problems when they meet them in the exam

  • 6 Examination power dynamics are different from the clinical environment, with institutional power residing with the patient and the exam, not the doctor. This might have a greater impact on those accustomed to hierarchical healthcare systems

  • 7 Differing cultural ethical approaches4—for example, using relational approaches to autonomy versus individual approaches

  • 8 Medical jargon is often seen as good practice outside the UK.

These eight points outline possible reasons why ethnicity, training experience, and sex can disadvantage certain candidate groups in a high stakes simulated environment. Like a juggler, the more balls a candidate has to juggle, the harder the exam becomes to pass. Should doctors who perform well in the real environment fail this exam because they cannot perform in a simulated environment?


Cite this as: BMJ 2013;347:f6438


  • Competing interests: I am FRCGP, BMA member; MRCGP examiner 2001-13, training programme director 2005-13, author of Essential nMRCGP CSA Preparation and Practice Cases.

  • Full response at: www.bmj.com/content/347/bmj.f5662/rr/664516.


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