Media GP. Past BMA and RCGP Council rep. Runner up RCGP President 2009. Highest ranked female candidate for RCGP President 2012. Authored 18 books. Twice BMA highly commended author. Retired mrcgpcourses.co.uk GP educator. Personal views. IG: unacoales Twitter: @drunacoales
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
10 Jul 2009
complaints being registered about racial bias in the CSA, Dr Una Coales gives
her view on how candidates can try to neutralise subjective bias.
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.
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,
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.
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
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.
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.
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
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.
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.
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.
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.
only did he pass his exam but he informed me that he noticed a huge difference
in the way patients interacted with him. QED.
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