Sunday, 23 September 2012

Pulse GP magazine, 10 July 2009. Neutralising bias in the CSA

This is what I really said back in 2009 (reprinted in my CSA book published in 2010) in Pulse GP magazine which has a circulation of approximately 30,000 GPs, to advise doctors sitting their MRCGP CSA GP licensing exam and why...

 
 

Neutralising bias in the Clinical Skills Assessment

(CSA)

 
10 Jul 2009
 
With complaints being registered about racial bias in the CSA, Dr Una Coales gives her view on how candidates can try to neutralise subjective bias.

The CSA is a subjective exam in which, as with other social interactions, cultural 'bias' can come into play. But there are things you can do to minimise it.
Watch a video of your consultation and turn down the volume. Just focus on observing you. Now write a list of critical comments. Be harsh and honest. Your list could consist of ….too fat, dress is too floral, unshaven, dark skin, too camp, etc.
Yes, I mean be brutally honest as this is how the outside world may perceive us, including the actors and examiners who have never made our acquaintance. My list, as a GP registrar, read: hair too long, needs to be tied up in a bun, exposed all my arms, too much flesh, not professional, need to put on a suit and cover my arms.
I know what you are thinking. I can't change my skin colour. I can't lose 2 stone in 2 months. And why should I, when it makes no difference to be ability as a doctor?
Let's take the latter example to begin with. How do we neutralise a cultural bias against obesity? Patients take one look and are less inclined to heed your advice to take up exercise and go on a diet. You know what they are thinking. ‘Why don't you take your own advice!' The solution is to project an image of Father Christmas. Put your hands on top of your protuberant abdomen, with your fingers interlocking but open. This projects a paternal image and suddenly your patients and the observing examiner are not distracted by your majestic size. In other words you have neutralised a potentially negative observer bias.
Why is it not good to wear a floral skirt or dress? Patients judge you on your attire. If you dress how they perceive a nurse would dress, they have difficulty believing they are seeing ‘the doctor'. Sorry women, but despite the fact two thirds or more of new doctors are female, alas people still address my husband as Dr Coales. So for the CSA exam and when you're in post, I'd recommend wearing a black or navy blue conservative skirt suit to project professionalism.
Last week a patient declared to me that he wished to see me again because I was professional. I wore a suit. Members of the public also like value for money. They pay £100 for a 20-minute consultation with a private GP, expect him to be wearing a tailor-made suit with impeccable manners and think they are getting a better service. Irrational but there you have it, public perception - especially relevant in the context of revalidation incorporating patient satisfaction surveys.
If you have a beard or moustache and there are no religious reasons for having it (if you are a Sikh, for example), my advice is shave it off. It will grow back. What subconscious image might it project when a male professional sports facial hair…unclean, deceitful, hiding a weak jaw-line? It's hard to find positive traits. And as women are more judgmental than men and examiners are also invited from the Ministry of Defence, it helps to present a clean shaven face. Grooming is essential! And that includes removing nose piercings, multiple ear piercings and taking a shower to prevent b.o. I've seen it all.
Now we come to the sensitive topic of ‘race'. If there is any subjective bias based on colour, this is the fault of the examiners and the college and needs to be eradicated. But there are other factors.
Nigerians, for example, are quoted to have a CSA pass rate of 44% and Indians of 48% in the latest RCGP report. Having met numerous Nigerian GP trainees in my courses, I find their English fluent and most go on to pass but some candidates of Asian origin are more greatly hampered by language. For me, as a teacher, the male Asian candidate, for whom English is not their first language, is the most challenging to help clear this exam. If such a male candidate is based in Scotland or Wales, I ask him to focus on emphasizing the lyrical Scottish or Welsh accent. What I am trying to do is neutralise the immediate impression formulated that the candidate before the observer is foreign.
And finally the ‘too camp' category. One candidate was facing a 3rd sitting and yet no one had told him that his mannerisms, gait and speech were too overtly gay, and that he was sitting an exam administered by a right-wing conservative Royal College. So I advised him to lower and deepen his high-pitched voice and neutralise his body movements. He went back to his surgery, practiced his speech until his voice went hoarse and modified his body language.
Not only did he pass his exam but he informed me that he noticed a huge difference in the way patients interacted with him. QED.
All of my suggestions are simply about getting you through the CSA. They're about changing your image to get you through this one assessment. They're not about changing who you are.
Dr Una Coales: There are things you can do to neutralise subjective bias Dr Una Coales: There are things you can do to neutralise subjective bias


READERS' COMMENTS


Anonymous,
11 Jul 2009
Thank you Dr. Una Coales for an excellent advice, although primarily meant for candidates sitting CSA exam but I believe its an essential reading for ALL GPs, specially countries other than UK. It will help the readers to be perceved as more professional both by examiners and by the patients. Dr Maqsood Ali, MRCGP, FCCP



Anonymous,
14 Jul 2009
what to say una, u r always great. i did spend 100 on a pen from goldsmith shop and posh suit 300. but i might look more smarter in my 3rd sitting because i have lost 7-8 kg over 1-2 months.
i remember ur advice i will speak to u soon. thanks for helping everybody to pass this exam. manmohan singh


RCGP investigates racial bias in new membership exam

24 Jun 2009
By Lilian Anekwe
The RCGP is providing extra training for nMRCGP examiners after complaints that its new exam was discriminating against ethnic minority doctors, Pulse can reveal.

The RCGP is providing extra training for nMRCGP examiners after complaints that its new exam was discriminating against ethnic minority doctors, Pulse can reveal.
The British International Doctors' Association submitted a complaint to the college after an analysis showed Asian GPs and those who qualified abroad had substantially lower pass rates in a key component of the exam than white candidates.
Some GPs warned that the clinical skills assessment part of the nMRCGP might be culturally biased, with concern that training practices in deprived areas could be hit by the unexpectedly high failure rates among ethnic minority doctors.
The college's report of the 2008 results shows 93.3% of white candidates passed the CSA, which is essential for overall success, compared with only 63.9% of Asians and 71.6% of those from other ethnic groups.
The key driver for the disparity appeared to be a marked difference between the performance of candidates who qualified at UK medical schools and those who studied overseas.
Some 91.6% of UK graduates passed, compared with 72.0% for other European countries, 48.7% for doctors from India, 52.9% for those from Pakistan and 54.5% for those from Sri Lanka.
An analysis of results from the old MRCGP exam, published in July 2007, showed that although there were differences between UK and Asian GP pass rates, they were not as striking – with an average disparity of 5.4 percentage points.
‘There are differences in the performance of the two major identifiable ethnic groups of UK graduate,' a report by the college on the new exam states. ‘This finding might suggest the examiners could be being unfairly biased.'
But it goes on to insist the college was satisfied that ‘although variations between performance of candidate groups were apparent', the ethnicity of examiners did not affect pass rates in those groups, and therefore ‘the indication is no unfair discrimination has been identified'.
But Pulse has learned that despite those reassurances, the college has been alerted to the possibility of bias and is taking measures to redress the balance.
Dr Nadim Fazlani, a GP in Liverpool and one of a handful of Asian nMRCGP examiners, said: ‘Some training was given by a professor of linguistics, as we're trying to assess a complex interaction between GP and patient that can be difficult to interpret in foreign doctors.'
Dr Sabyasachi Saker, national chair of the British International Doctors' Association, told Pulse: ‘We have expressed our concerns to the RCGP through [vice chair] Dr Hasmukh Joshi and he said the college was looking into the matter.'
South London GP Dr Una Coales, a GP trainer, said: ‘Language barriers cannot account for a 30% difference in pass rate. Cultural and gender difference can also affect how some doctors interact with patients.'
Dr Una Coales: training in some countries is based on treating the condition, rather than the patient Dr Una Coales: training in some countries is based on treating the condition, rather than the patient

READERS' COMMENTS


Anonymous,
24 Jun 2009
It was definitely something noted by candidates of non white origin before the exam and while waiting for the results... communication skills being the downfall??? Ranjan Dass
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Anonymous,
24 Jun 2009
I definetly agree with the above article. I think BEM drs are victimised and sterotyped to fail esp among the Male drs, as compared to Female and british graduates.. the statistics are obvious. I have passed my WBPA and AKT for the first time, but CSA failed three times. Feedback from trainers and patients and staff and colleagues contradicts the feedback from the exam...i hope this matter be fully investigated and some decisions will be overturned. esp those who passed half of the stations.... zimnako rashid
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Anonymous,
24 Jun 2009
I am one of the victims of this so called "culture bias" and am devastated by the new csa exam system. The feedback I have received from individual patients and staff has always been above the level of the peer group. My trainer and other trainers in the practice feel I am doing well and have good clinical and communication skills and am up to the level of other practising GPs.

In the exam I felt I had done well, but the cases which I was not sure of passing i have passed and cases which I never thought of failing I have not passed. It's confusing, as the feedback that we receive from the exam is not detailed and or constructive.

I hope there will be a more structured examining process in the future with options for the candidates to appeal against the marking system. purandhar nosina
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Anonymous,
26 Jun 2009
I may need to agree with the above said statements. Although i was not sure that it happens in exams. I just sat the CSA recenty unsuccessfully. I feel I need to change my views. In view of the number of Overseas doctors failing the CSA and the number of Bristish grads failing in the AKT. I wonder what the Exam board has to say for that. AKT
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Anonymous,
26 Jun 2009
I totally agree with your comments. It's interesting that Brit grads are failing the AKT but foreign Drs are failing the CSA.

I share the sentiments of Dr Nosina. I passed my AKT, had excellent MSF and was even offered a job before my exam results were out, but failed the CSA.

The problem was, I thought I had passed the CSA with flying colours. The feedback was extremely vague and generalised, there seems to be a definite bias in the evaluation process, and for the price we pay, both financially and resulting in a delay of career progression, I feel the CSA should be suspended until these issues are ironed out. MR
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Anonymous,
26 Jun 2009
Very unfair exam the CSA is. Not a single Brit grad failed in my scheme. I passed my AKT with above average mark and my trainer's report and patient satisfaction questionnaires were very good. During the CSA exam, actors have given me extremely hard time.

They appeared sarcastic and critical and gave me more of a challange. They exaggerated in trying to make it difficult for me to extract data and history from them more that what they may have been asked to do. Therefore, if they do not give me history, then how can I make a management plan?

In real life patients are not like this. Actors have also asked me very technical and difficult questions which I would expect RCGP viva examiners to ask. Examiners were also too harsh. I do not know why I failed and consequently I do not know how to pass next time!! Also the exam fees are more than double the exam fees for any other royal college which is completely unfair. k El-Namasy
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Anonymous,
27 Jun 2009
I strongly believe this examination is absolutely biased, unprofessional ,language examination ,nothing to do with clinical and professional competencies ,how on earth a medical consultant can fail ,headache ,palpitation ,and earache cases ,,, unbelievable .this examination ,does need some external assesor to look into it .why only picking up foriegn graduate only.remember Shipman was british graduate ,wrecking around human lives for thirty whole years without being picked up by local authorities .what lessons british establishment learnt from that ,,nothing. abu hamzah
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Anonymous,
27 Jun 2009
At least some light shed on this even thought for me personally it's going to be my 4th attempt in September, better late than never as they say! pep
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Anonymous,
30 Jun 2009
I strongly agree with above. I was almost shocked when i received my results ie i failed to diagnose sore throat and i was not sympathetic /doctor centered and basically a completely fool!!!

It was like a hide and seek game .... no one telling what's wrong with them even if u ask them a few times. The exam was for post graduate linguistic skills rather than clinical scenarios. Moreover the fee for exam is sky high and college should do somthing about it.

I think the college should re consider the way they conduct exams. I hope some one takes notice and help us how we are going to sit in the exam again,
zakir mulk
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Anonymous,
17 Jul 2009
I had a look at the RCGP statistics while preparing for my CSA examinations.the results was alarming and i was apprehensive as i am both a non-UK graduate and also a male.
Though i passed my CSA at first attempt, i have to agree, some patients do make the consultation more difficult. In particular, i had a patient who seemed not to understand whatever i was asking or saying.I was amazed because I ensured that i speak slowly and with clarity in my exams, as i'd been seeing a voice coacher for a while. It was pretty obvous even to the lame that the actor was just making the consultation difficult. Like many of the above remarks, my PSQ was much above national average.
I have to agree though that the examination is not about knowledge, but about communication skills. It is about how you consult patients -t aking the history,picking up cues, delivering the explanation and showing emotions.
We, non-uk males are in a difficult position because we are so "not- good" at expressing emotions, compounded by the fact that culturally the way we do it is so much different. It's basically a game that we to play and act for the duration of the examination.
For a fact, many non-uk graduates are more intelligent than our locally graduated peers - i could see that in my own group, but what these people are good at, is the way they get around difficult situations by talking their way through. Like i am being constantly reminded in my practice, it doesn't matter whether you have missed a diagnosis and did a medical blunder, but if you have talked nicely to the patient and family,you'll get by without much hassle. what a sad reality - message is you do not have to be medically competent but needs to have good communication techniques. Iswaraj Ramracheya
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Anonymous,
22 Jul 2009
CSA is unfair. Having failed it 3 times with a mark of 7 on all 3 occassions , I passed it the 4th time. But hey, u know what, if one is good, one thing is for sure u will come out smiling in the end, i am a partner now!! Renju Mathews
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Anonymous,
22 Jul 2009
i have lived and worked in this country for the last 20 years. i completed my ST3 last year and i sat both AKT and CSA exams. i have to agree with the comments above. i failed marginally my CSA when no other british candidate from my group did. i was also considered to be 'doctor centred' by the examiners to mine and my trainer's surprise who said 'we don't see that here' when he read the report on line with me. the actors were very good, too good at concealing their hidden agenda which doesn't usually happen with real patients. i did find the whole experience extremely harsh, traumatic, tiring and even surreal. and i'm convinced there is a bias towards british trained doctors and against non brits. Ricardo Jose Martinez Ramos
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Anonymous,
09 Aug 2009
Is it honestly any surprise that some of the above candidates failed? Half of these comments are grammatically incorrect, mis-spelt or just do not make sense. If you are unable to speak english fluently or near fluently there is no doubt you will miss the subtleties of the doctor patient interaction. There is no place in the UK for doctors who are unable to communicate adequately. Matt Islet
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Anonymous,
12 Sep 2009
Matt I think you misspelled 'misspelt' wrong - there is no hyphen. Abid Ali Khan
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Anonymous,
08 Oct 2009
finally passed... am pleased and relieved... never mind the wrong spelling Matt, it's your luck and this kinda article that made a difference. zimnako rashid
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Anonymous,
06 Nov 2009
Well said AA Khan! pep
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Anonymous,
07 Mar 2010
Failed my csa exam and really surprised, because when I was doing role play with my colleagues, all were local graduates, I was one of them who was very sensitive and was taking very mature approach when it came to management plan!! I dont know what to say, only that the idea of this exam is to make a life very difficult for overseas doctors and nothing else!!!! we have to pay a lot only because we happened to be here working in this country like a dog!! put up with every bulling and etc not being able to say anything because would threatened our future just suffer and shut up. I can see now whose talking about empathy and sympathy, People designed this exam have no idea about these words, yes we have to learn how to play roles and act even not believe any of these just like everybody else passed this exam!!!!! csa
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